The impact of relationship dynamics on the detection and reporting of elder abuse occurring in domestic settings.

There is a keen desire to increase the detection and reporting of elder abuse. The purpose of this study was to describe the circumstances under which abuse is detected and reported and to identify the relationship dynamics that might be impacting detection and reporting decisions. Interviews were conducted with 71 Adult Protective Services (APS) caseworkers, 55 of their elderly clients, and 32 third-party adults. Detection and reporting are distinct but related acts. The temporal relationship between detection and reporting generally differed depending on the nature and quality of the relationship between (a) the victim and offender and (b) the victim and reporter. Efforts to increase reporting may benefit from taking into consideration these relationship dynamics. A range of individuals detected and reported elder abuse, including victims, under a range of circumstances, reinforcing the value of public efforts to increase awareness of elder abuse.

How case characteristics differ across four types of elder maltreatment: implications for tailoring interventions to increase victim safety.

PURPOSE: The purpose of this study was to determine whether case characteristics are differentially associated with four forms of elder maltreatment. METHOD: Triangulated interviews were conducted with 71 APS caseworkers, 55 victims of substantiated abuse whose cases they managed, and 35 third party persons. RESULTS: Pure financial exploitation (PFE) was characterized by victim unawareness of financial exploitation and living alone. Physical abuse (PA) was characterized by victim's desire to protect the abusive individual. Neglect was characterized by isolation and victim's residing with the abusive individual. Hybrid financial exploitation (HFE) was characterized by mutual dependency. IMPLICATIONS: These differences indicate the need for tailoring interventions to increase victim safety. PFE requires victims to maintain financial security and independence. PA requires services to meet the needs of abusive individuals. Neglect requires greater monitoring when elderly persons reside with another person. HFE requires the provision of services to both members of the dyad.

How do abused elderly persons and their adult protective services caseworkers view law enforcement involvement and criminal prosecution, and what impact do these views have on case processing?

This study examined law enforcement and prosecution involvement in 71 cases of elder abuse where pure financial exploitation (PFE), physical abuse (PA), neglect (Neglect), or hybrid financial exploitation (HFE) (financial exploitation co-occurring with physical abuse and/or neglect) occurred in a domestic setting. Victims of elder abuse and assigned Adult Protective Services (APS) caseworkers were systematically interviewed. Law enforcement officials were involved in 54% of the cases, and 18% of the cases were prosecuted. PA was significantly more likely to trigger a law enforcement response and to be prosecuted than Neglect or PFE. HFE involved prosecution for assault rather than financial exploitation. Generally, the victims of elder abuse were not receptive to criminal justice involvement, which appears to have a significant impact upon the level of this involvement. The reasons for this reluctance are discussed, as well as the challenges and limitations of criminal justice system involvement and related implications for policy and practice.

Don't let go of the rope: reducing readmissions by recognizing hospitals' fiduciary duties to their discharged patients.

In the early years of the twenty-first century, it was widely speculated that massive, multi-purpose hospitals were becoming the "dinosaurs" of health care, to be largely replaced by community-based clinics providing specialty services on an outpatient basis. Hospitals, however, have roared back to life, in part by reworking their business model. There has been a wave of consolidations and acquisitions (including acquisitions of community-based clinics), with deals valued at $7.9 billion in 2011, the most in a decade, and the number of deals increasing another 18% in 2012. The costs of hospital care are enormous, with 31.5% ($851 billion) of the total health expenditures in the United States in 2011 devoted to these services. Hospitals are (1) placing growing emphasis on increasing revenue and decreasing costs; (2) engaging in pervasive marketing campaigns encouraging patients to view hospitals as an all-purpose care provider; (3) geographically targeting the expansion of their services to "capture" well-insured patients, while placing greater pressure on patients to pay for the services delivered; (4) increasing their size, wealth, and clout, with two-thirds of hospitals undertaking renovations or additional construction and smaller hospitals being squeezed out, and (5) expanding their use of hospital-employed physicians, rather than relying on community-based physicians with hospital privileges, and exercising greater control over medical staff. Hospitals have become so pivotal in the U.S. healthcare system that the Patient Protection and Affordable Care Act of 2010 (PPACA) frequently targeted them as a vehicle to enhance patient safety and control escalating health care costs. One such provision--the Hospital Readmissions Reduction Program, which goes into effect in fiscal year 2013--will reduce payments ordinarily made to hospitals if they have an "excess readmission" rate. It is estimated that adverse events following a hospital discharge impact as many as 19% of all discharged patients. When hospitals and similar health care facilities fail to adequately manage the discharge of their patients, devastating medical emergencies and sizeable healthcare costs can result. The urgency to better manage these discharges is compounded by the fact that the average length of hospital stays continues to shorten, potentially increasing the number of discharged patients who are at considerable risk of relapse. Also exacerbating the problem is a lack of clarity regarding who, if anyone, is responsible for these patients following discharge. Confusion over who bears responsibility for discharge-related preparation and community outreach, concerns about compensation, a lack of clear institutional policies, and the absence of legal mandates that patients be properly prepared for and monitored after discharge all contribute to the potential abandonment of patients at a crucial juncture. Although the PPACA establishes financial incentives for hospitals and similar facilities to combat the long-standing problem of high readmission rates, it does not provide a remedy for patients who have suffered avoidable harm after being discharged without adequate preparation or post-discharge assistance. This omission is particularly problematic as existing legal remedies, including medical malpractice suits, have provided little recourse for patients who have suffered injury that could have been prevented through the implementation of reasonable discharge-related policies. To protect the many patients who are highly vulnerable to complications following discharge and to provide them redress when needed services are not provided, hospitals' obligations to these patients should be recognized for what they are: a fiduciary duty to provide adequate discharge preparation and post-discharge services. The recognition of this duty is driven by changes in the nature of hospital care that enhance the perception that hospitals have become a "big business" that should "carry their own freight." Properly interpreted, this duty requires facilities to implement an appropriate discharge plan and provide post-discharge services for a period of time commensurate with a patient's continuing health risks. Notably, this is not the same as a generalized duty to provide all patients with continuing post-discharge treatment. It is a more limited obligation to offer necessary clarification and direction to patients upon discharge, and to institute a reasonable post-discharge monitoring program for patients with continuing health risks.

Enhancing the safety of elderly victims after the close of an APS investigation.

PURPOSE: The purpose of this study was to test whether particular actions on the part of adult protective services (APS), the elderly victim, and/or society's response to abusive individuals, are associated with the continuation of abuse after the close of an APS investigation and thereby compromise victim safety. METHOD: Interviews were conducted with 71 APS caseworkers, 55 of the elderly victims of substantiated abuse, and 35 third-party persons. RESULTS: A small proportion of elderly victims continue to experience abuse after the close of an APS investigation. Elderly victims were more likely to experience continued abuse when they chose to have ongoing contact with their abusers, vis-à-vis cohabitation or otherwise, and when their abusers experienced no consequences. Although continuation of abuse did not differ by the type of maltreatment involved, reasons for the cessation of abuse, and other safety indicators, did. IMPLICATIONS: To enhance victim safety, greater monitoring may be warranted in cases wherein elderly victims continue to have contact with their abuser and when abusive individuals experience no consequences. To further enhance victim safety, abusive individuals must be incorporated into an overall strategic response to elder abuse. A potential avenue for facilitating victim safety while maintaining victim autonomy is to understand their motivations for desiring continued contact with their abuser and developing interventions based upon such knowledge.

The Health Care Reform Act of 2010 and Medical Malpractice Liability: Worlds in Collision or Ships Passing in the Night.

The Patient Protection and Affordable Care Act of 2010 tackles many health care-related issues, but medical malpractice liability reform is not one of them. Despite being a perennial target of health care reform-with accompanying assertions that a medical malpractice liability crisis is corrupting the delivery of health care in the United States-only three short sections that made little substantive change to existing law were devoted to it in a bill that eventually totaled over 900 pages in length. This Article describes what the bill did, what it failed to do, and its likely and perhaps unanticipated consequences for the ongoing medical malpractice liability reform debate.

Risk factors associated with elder abuse: the importance of differentiating by type of elder maltreatment.

Elder abuse research rarely differentiates by the type of elder maltreatment involved when identifying risk factors. The purpose of this study was to compare risk factors across four predominant types of elder maltreatment (financial exploitation, physical abuse, neglect by others, and hybrid financial exploitation [HFE]). Data were collected from two sources: interviews with victims of substantiated elder abuse, responding adult protective services (APS) caseworkers (N = 71), and third-party informants; and a statewide database that contained all substantiated cases over a corresponding 2-year period (N = 2,142). Using chi-square (interview data) and logistic regressions (Adult Services/Adult Protective Services [ASAPS] data), significant differences across the four types of elder maltreatment were found. These two datasets provide converging evidence for the importance of differentiating by type of maltreatment when identifying risk factors for elder maltreatment and for the importance of considering both the elderly victim and the abusive individual when predicting type of elder maltreatment.