Exploring Staffing Levels in Adult Day Services: Does Profit Status Matter?

OBJECTIVE: For more than 4 decades, adult day service centers (ADSCs) have provided long-term care services and socialization to hundreds of thousands of people in the United States. An important part of the long-term care continuum, ADSCs serve older adults and adults with disabilities, many of whom have low incomes and are racial and ethnic minorities. Yet, little is known about the quality of ADSCs. To better understand ADSC quality, we examined staffing levels, a key aspect of organizational structure. Staffing levels are an established quality measure associated with resident outcomes in nursing homes. Our study compares ADSC staffing levels between for-profit and nonprofit or government-operated ADSCs. DESIGN: Cross-sectional secondary data analysis using a nationally representative survey of ADSCs. SETTING AND PARTICIPANTS: Adult day service center (n = 573) directors completed a survey as part of the 2018 National Study of Long-Term Care Providers. METHODS: Bivariate comparisons and multivariate linear regression were used to compare staffing, measured as hours per participant day in nonprofit and for-profit ADSCs. RESULTS: Approximately 60% of ADSCs in the sample were nonprofit or government-operated and the remainder were for-profit. For-profit ADSC staffing averaged 1.5 hours per participant day and nonprofit or government-operated ADSC staffing averaged 1.9 hours per participant day. For-profit ADSCs had 15.8% (P = .047) lower hours per participant day compared with nonprofit ADSCs after controlling for center characteristics, such as Medicaid use, participant acuity, and ADSC size. CONCLUSION AND IMPLICATIONS: We found that for-profit ADSCs have lower staffing levels compared with nonprofit and government-operated ADSCs. Future research is needed to understand how staffing levels relates to the quality of care in for-profit and nonprofit ADSCs and how these relationships vary by participant characteristics, such as income, race/ethnicity, and acuity.

Comprehensive Older Adult and Caregiver Help (COACH): A person-centered caregiver intervention prevents elder mistreatment.

BACKGROUND: Elder mistreatment (EM) harms individuals, families, communities, and society as a whole. Yet research on interventions is lagging, and no rigorous studies demonstrating effective prevention have been published. This pilot study examines whether a first-of-its-kind coaching intervention reduced the experience of EM among older adults with chronic health conditions, including dementia. METHODS: We used a double-blind, randomized controlled trial to test a strengths-based person-centered caregiver support intervention, developed from evidence-based approaches used in other types of family violence. Participants (n = 80), family caregivers of older adults who were members of Kaiser Permanente, completed surveys at baseline, post-test, and 3-month follow-up. The primary outcome was caregiver-reported EM; additional proximal outcomes were caregiver burden, quality-of-life, anxiety, and depression. Nonparametric tests (Mann-Whitney U, Fisher's Exact, Wilcoxon Signed Rank, and McNemar's) were used to make comparisons between treatment and control groups and across time points. RESULTS: The treatment group had no EM after intervention completion (assessed at 3-month follow-up), a significantly lower rate than the control group (treatment = 0%, control = 23.1%, p = 0.010). CONCLUSIONS: In this pilot study, we found that the COACH caregiver support intervention successfully reduced EM of persons living with chronic illness, including dementia. Next steps will include: (1) testing the intervention's mechanism in a fully powered RCT and (2) scaling the intervention for testing in a variety of care delivery systems.

Conceptualizing Person-Centered Care in Elder Mistreatment Intervention: Use of a Well-Being Framework.

BACKGROUND AND OBJECTIVES: Person-centered care (PCC) applied to elder mistreatment interventions is an approach to include victim priorities. Although PCC may improve outcomes by supporting choice, victim preferences are often difficult to support, especially in high-risk situations. We studied the adaptation of PCC structures and process to a pilot intervention, aimed at including client preferences in a multidisciplinary team's plans to address complex elder mistreatment. RESEARCH DESIGN AND METHODS: Case study analysis was used to examine the process of integrating client priorities into a risk-reduction plan. A well-being framework was used to understand the relationship between safety and preferences. Purposive sampling identified a case study of a high-risk victim with history of refusing help who agreed to work with the Service Advocate, a member of a multidisciplinary team. RESULTS: PCC required a relationship of trust, honed over several weeks by prioritizing the clients' perspective. Client preferences included remaining at home, continuing the relationship with the abuser, and maintaining a sense of mastery. Individualized definitions of "safety" were unrelated to elder mistreatment risk. Assistance included working with the suspected perpetrator, which is not offered by most elder mistreatment interventions, and resulted in some risk reduction. Reasons for refusing help were a desire for control and fear of loss of well-being assets. DISCUSSION AND IMPLICATIONS: Individualized definitions of well-being should be considered in measuring intervention success. Future research could determine guidelines on what levels of elder mistreatment risk are acceptable, and how to monitor clients for safety while supporting autonomy.

It's Time We Looked Under the Hood: An In-Depth Examination of Five Public California Area Agencies on Aging.

BACKGROUND AND OBJECTIVES: As the older adult population grows, it is important to understand the effectiveness of service delivery systems that support aging in place. Studying service delivery processes and organizational structures of Area Agencies on Aging (AAAs) is essential for future efforts to understand service delivery outcomes and innovations. RESEARCH DESIGN AND METHODS: We conducted site visits with 5 government-run California AAAs. We used a template and constant comparative analysis to analyze transcripts from site visits and focus groups with key informants. RESULTS: AAA representatives discussed how their organizational structure was related to (a) which services and programs they provided; (b) administrative cost savings and access to funding sources; (c) inter- and intra-agency coordination; and (d) visibility among clients and community partners. DISCUSSION AND IMPLICATIONS: These findings can be used to guide decisions surrounding how changes in AAA structure may affect funding, coordination, service delivery, and visibility, among other factors. Consolidating the AAA with other departments and programs facilitates coordination and shared administrative costs, yet consolidation may reduce standalone AAAs' visibility and ability to innovate. AAA structure should be tailored to fit community resources, local government organization, and the needs of older residents.

Elder abuse in the COVID-19 era based on calls to the National Center on Elder Abuse resource line.

BACKGROUND: The COVID-19 pandemic has exacerbated circumstances that place older adults at higher risk for abuse, neglect, and exploitation. Identifying characteristics of elder abuse during COVID-19 is critically important. This study characterized and compared elder abuse patterns across two time periods, a one-year period during the pandemic, and a corresponding one-year period prior to the start of the pandemic. METHODS: Contacts (including social media contacts, and email; all referred to as "calls" for expediency) made to the National Center on Elder Abuse (NCEA) resource line were examined for differences in types of reported elder abuse and characteristics of alleged perpetrators prior to the pandemic (Time 1; March 16, 2018 to March 15, 2019) and during the pandemic (Time 2; March 16, 2020 to March 15, 2021). Calls were examined for whether or not abuse was reported, the types of reported elder abuse, including financial, physical, sexual, emotional, and neglect, and characteristics of callers, victims, and alleged perpetrators. Chi-square tests of independence compared frequencies of elder abuse characteristics between time periods. RESULTS: In Time 1, 1401 calls were received, of which 795 calls (56.7%) described abuse. In Time 2, 1009 calls were received, of which 550 calls (54.5%) described abuse. The difference between time periods in frequency of abuse to non-abuse calls was not significant ([Formula: see text]). Time periods also did not significantly differ with regard to caller, victim, and perpetrator characteristics. Greater rates of physical abuse ([Formula: see text] and emotional abuse ([Formula: see text] were reported during Time 2 after adjustment for multiple comparisons. An increased frequency of multiple forms of abuse was also found in Time 2 compared to Time 1 ([Formula: see text]. CONCLUSIONS: Findings suggest differences in specific elder abuse subtypes and frequency of co-occurrence between subtypes between time periods, pointing to a potential increase in the severity of elder abuse during COVID-19.

Voices of Experience: What Do Low-Income Older Adults Tell Us About Mobility, Technology, and Social Participation?

Mobility and technology can facilitate in-person and virtual social participation to help reduce social isolation, but issues exist regarding older adults' access, feasibility, and motivation to use various forms of mobility and technology. This qualitative study explores how a diverse group of low-income, urban-living older adults use mobility and technology for social participation. We conducted six focus groups (N = 48), two each in English, Spanish, and Korean at a Los Angeles senior center. Three major themes emerged from thematic analysis: using technology for mobility; links between mobility and social participation; and technology-mediated social participation. Cost, perceived safety, (dis)ability, and support from family and friends were related to mobility and technology use. This study demonstrates the range of mobility and technology uses among older adults and associated barriers. The findings can help establish a pre-COVID-19 baseline on how to make mobility and technology more accessible for older adults at risk of isolation.

Improving forensics: Characterizing injuries among community-dwelling physically abused older adults.

BACKGROUND: Physical elder abuse affects a substantial number of older adults, leaving victims at increased risk for negative health outcomes. Improved detection of abuse-related injuries may increase victim access to professional support, but providers report difficulties distinguishing between accidental and abuse-related injuries, due in part to victims' pre-existing health conditions and medication use. OBJECTIVES: To describe the spectrum and characteristics of injuries among physically abused older adults and identify injury characteristics associated with abuse. DESIGN: Case-control study. SETTING: Physically abused adult protective services clients were interviewed in their home; non-abused comparison group participants were interviewed in an outpatient geriatrics clinic. PARTICIPANTS: Sample included 156 community-dwelling adults aged 65 and older, including 57 physically abused and 99 non-abused individuals. Self-reported abuse history was confirmed through independent case assessment by a LEAD (Longitudinal, Expert All-Data) panel of clinicians with family violence expertise. MEASUREMENTS: Full-body assessments were conducted, documenting injury incidence, diagnosis, and location. We also collected sociodemographic characteristics, level of social support, functional ability, medical history, and medication use. RESULTS: Physically abused older adults were more likely to be injured upon assessment (79.0% vs 63.6%; p < 0.05) and have a greater number of injuries ( x¯=2.9 vs x¯=2.0 , p < 0.05). Injuries seen more often among abused individuals included: upper extremity ecchymoses (42.1% vs 26.3%; p < 0.05), abrasions (31.6% vs 11.1%; p < 0.01), and areas of tenderness (8.8% vs 0.0%; p < 0.01); and head/neck/maxillofacial ecchymoses (15.8% vs 2.0%; p < 0.01) and tenderness (15.8% vs 0.0%; p < 0.001). Lower extremity abrasions (12.3%) were common but unrelated to abuse status. CONCLUSION: While physical abuse does not always result in physical injury, victims more commonly display head/neck/maxillofacial ecchymoses or tenderness and upper extremity abrasions, ecchymoses, or tenderness. Detection of these injuries among older adults warrants further interview and examination.

Longitudinal Assessment of the Relationships Between Geriatric Conditions and Loneliness.

OBJECTIVES: In response to the lack of longitudinal evidence, this study aims to disentangle time sequence and directionality between the severity of geriatric conditions (GCs) and loneliness. DESIGN: Longitudinal panel study. SETTING AND PARTICIPANTS: The working sample had 4680 participants of 2006, 2010, and 2014 waves of the Health and Retirement Study (HRS). All participants were at least 65 years old at baseline. Proxy responded cases and individuals who suffered from moderate to severe cognitive impairment were excluded from the analysis. METHODS: Loneliness was measured with the 3-item UCLA loneliness scale. Five GCs were included: falls, incontinence, vision impairment, hearing impairment, and pain. Severity indicators were the number of times fallen in the past 2 years, number of days experiencing loss of bladder control in the past month, self-rated eyesight, self-rated hearing, and participants' perceived level of pain. RESULTS: Random-intercept cross-lagged panel models were run to analyze the relationship between the severity of each individual GC and loneliness. All models were controlled for baseline demographics, social isolation, self-rated health, physical function, comorbidities, and hospitalization. The longitudinal association between loneliness and fall was bidirectional: a higher loneliness score predicted an increased number of falls and vice versa. Incontinence, vision impairment, hearing impairment, and pain were not significantly associated with loneliness longitudinally. The association between the random intercept of loneliness and some GCs (vision and pain) were significant, indicating the severity of these GCs were related to loneliness at the between-person level at baseline. CONCLUSION AND IMPLICATIONS: Findings of the longitudinal analysis suggest a reciprocal relationship between fall and loneliness. Fall prevention programs could be integrated with social service for addressing loneliness, and alleviating loneliness might be beneficial for preventing falls. Results of this study highlight the importance of integrating clinical management of falls with social services addressing loneliness in long term care.

Transforming Aging Services: Area Agencies on Aging and the COVID-19 Response.

For over four decades, Area Agencies on Aging (AAAs) have served as focal points to help older adults remain in their homes and communities. AAAs partner with other organizations to administer services authorized under the Older Americans Act (OAA). AAAs represent loosely coupled systems; they are responsive to guidelines established by the OAA while maintaining flexibility to leverage limited resources, establish partnerships, and create innovative programs to meet community needs. As stay-at-home orders and concern for safety have kept many older adults homebound during the coronavirus disease 2019 (COVID-19) pandemic, an important question is how the Aging Network, including the over 600 AAAs, has responded to these rapidly changing needs. Although time and more systematic assessments are required, available information suggests that the loosely coupled network of AAAs has been a key, adaptable resource. This article begins with a description of the Aging Network and its history before turning to how the community-specific, collaborative, and evolving nature of AAAs places them at a unique position to respond to the challenges that arise with COVID-19. It concludes with how AAAs can continue to adapt to meet the needs of older adults and the people who care for them.

Who is in the revolving door? Policy and practice implications of recurrent reports to adult protective services.

Repeat referral to adult protective services APS (recurrence) is a much-discussed topic among APS agencies as it may indicate ongoing harm, yet there is limited research examining prevalence or causes. This paper provides a foundational investigation of recurrence within a California APS county program. Drawing from thirty-three months of de-identified reports, we used logistic regression to examine the impact of intake report characteristics on repeat referral within one year after baseline case closure. One-fifth of the sample was recurrent (19.9%, n=987/4,958), with self-neglect being the most common type of report to recur (14.3%, n=307/2,141). Overall recurrence was predicted by female gender, older age, living alone, and multiple elder abuse, neglect, and exploitation (ANE) types reported at baseline, and report placed by social service provider, friends, family, landlords, and victim self-reports. Reporters personally related to the victim and social service providers are potential partners in identifying ANE, and alternate intervention approaches may be necessary.

Elder Abuse Characteristics Based on Calls to the National Center on Elder Abuse Resource Line.

Characterizing the types of elder abuse and identifying the characteristics of perpetrators are critically important. This study examined the types of elder abuse reported to the National Center on Elder Abuse (NCEA) resource line. Calls were coded with regard to whether abuse was reported, types of abuse alleged, whether multiple abuse subtypes occurred, and who perpetrated the alleged abuse. Of the 1,939 calls, 818 (42.2%) alleged abuse, with financial abuse being the most commonly reported (449 calls, 54.9%). A subset of calls identified multiple abuse types (188, 23.0%) and multiple abusers (149, 18.2%). Physical abuse was most likely to co-occur with another abuse type (61/93 calls, 65.6%). Family members were the most commonly identified perpetrators (309 calls, 46.8%). This study reports the characteristics of elder abuse from a unique source of frontline data, the NCEA resource line. Findings point to the importance of supportive resources for elder abuse victims and loved ones.

Toward a better understanding of the elder abuse forensic center model: comparing and contrasting four programs in California.

Resolving elder abuse, neglect, and self-neglect often requires the authority and expertise of multiple providers. Prior research of the elder abuse forensic center (FC) model, although limited, has indicated strong member support, increases in prosecution of abusers, and increases in conservatorship for those lacking capacity. This study expands on previous single-site research by conducting a cross-site multimethod evaluation of four established FCs to better describe the model and inform its replication with fidelity. Data were compiled from FC administrative data, site visits completed from 2011-2012, and a follow-up telephone interviews conducted in 2018. Site characteristics, processes, desired outcomes, and long-term sustainability were compared. All FCs had dedicated staff who convened a multidisciplinary team (MDT) of medical, legal, and social services providers to jointly engage in case review, consultation, and provision of supportive professional services. Similar results were observed across all sites in team effectiveness and member-perceived improvements in personal practice and inter-agency relationships. While three programs had unified philosophies and practice approaches, one employed a distinct model and was no longer in operation at follow-up. Commonalities in case characteristics, program structure, processes, and outcomes provide insight into the core model components and a foundation for continued program replication and standardization.

The Prevalence of Self-Reported Elder Abuse Among Older Women in Community Settings: A Systematic Review and Meta-Analysis.

The abuse of older women appears to be a significant problem. Developing a better understanding of the extent of the problem is an important step toward preventing it. We conducted a global systematic review and meta-analysis of existing prevalence studies, in multiple languages, that occurred in the community settings from inception to June 26, 2015, in order to determine the extent of abuse against women aged 60 years and over. To disentangle the wide variations in prevalence estimates, we also investigated the associations between prevalence estimates and studies' demographic and methodological characteristics. A total of 50 studies were included in the meta-analysis. The combined prevalence for overall elder abuse in the past year was 14.1% (95% confidence interval (CI) [11.0, 18.0]). Pooled prevalence for psychological abuse was 11.8% (95% CI [9.2%, 14.9%]), neglect was 4.1% (95% CI [2.7%, 6.3%]), financial abuse was 3.8% (95% CI [2.5%, 5.5%]), sexual abuse was 2.2% (95% CI [1.6%, 3.0%]), and physical abuse was 1.9% (95% CI [1.2%, 3.1%]). The studies included in the meta-analysis for overall abuse were heterogeneous indicating that significant differences among the prevalence estimates exist. Significant associations were found between prevalence estimates and the following covariates: World Health Organization-defined regions, countries' income classification, and sample size. Together, these covariates explained 37% of the variance. Although robust prevalence studies are sparse in low- and middle-income countries, about 1 in 6, or 68 million older women experience abuse worldwide. More work is needed to understand the variation in prevalence rates and implications for prevention.

What Can Elder Mistreatment Researchers Learn About Primary Prevention From Family Violence Intervention Models?

Elder mistreatment (EM) is a public health problem that harms millions of older Americans each year. Despite growing recognition of its occurrence, there are no evidence-based primary prevention programs. Although EM is distinct from other areas of family violence, including child maltreatment and intimate partner violence, common risk factors and theoretical underpinnings point to opportunities for prevention strategies. Drawing on evidence-based best practices found in other fields of family violence, we identify approaches that could be tested to prevent EM at the hands of family caregivers, who are among the most likely to commit mistreatment. Specifically, we examine home visiting approaches primarily used in the child maltreatment field and identify components that have potential to inform EM interventions, including prevention. We conclude that there is enough information to begin testing a prevention intervention for EM that targets caregivers.

Developing an undue influence screening tool for Adult Protective Services.

The study purpose was to develop and pilot an undue influence screening tool for California's Adult Protective Services (APS) personnel based on the definition of undue influence enacted into California law January 1, 2014. Methods included four focus groups with APS providers (n = 33), piloting the preliminary tool by APS personnel (n = 15), and interviews with four elder abuse experts and two APS administrators. Social service literature-including existing undue influence models-was reviewed, as were existing screening and assessment tools. Using the information from these various sources, the California Undue Influence Screening Tool (CUIST) was developed. It can be applied to APS cases and potentially adapted for use by other professionals and for use in other states. Implementation of the tool into APS practice, policy, procedures, and training of personnel will depend on the initiative of APS management. Future work will need to address the reliability and validity of CUIST.

Research Protocol for Systematic Review and Meta-Analysis of Elder Abuse Prevalence Studies.

Elder abuse is an important public health and human rights issue, yet its true extent is not well understood. To address this, we will conduct a systematic review and meta-analysis of elder abuse prevalence studies from around the world. This protocol describes the methodological approach to be adopted for conducting this systematic review and meta-analysis. In particular, the protocol describes the search strategies and eligibility criteria to be used to identify and select studies and how data from the selected studies will be extracted for analysis. The protocol also describes the analytical approach that will be used to calculate pooled prevalence estimates and discusses the use of meta-regression to assess how studies' characteristics influence the prevalence estimates. This protocol conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analysis - or PRISMA - guidelines and has been registered with the PROSPERO International Prospective Register of systematic reviews.

Elder abuse prevalence in community settings: a systematic review and meta-analysis.

BACKGROUND: Elder abuse is recognised worldwide as a serious problem, yet quantitative syntheses of prevalence studies are rare. We aimed to quantify and understand prevalence variation at the global and regional levels. METHODS: For this systematic review and meta-analysis, we searched 14 databases, including PubMed, PsycINFO, CINAHL, EMBASE, and MEDLINE, using a comprehensive search strategy to identify elder abuse prevalence studies in the community published from inception to June 26, 2015. Studies reporting estimates of past-year abuse prevalence in adults aged 60 years or older were included in the analyses. Subgroup analysis and meta-regression were used to explore heterogeneity, with study quality assessed with the risk of bias tool. The study protocol has been registered with PROSPERO, number CRD42015029197. FINDINGS: Of the 38 544 studies initially identified, 52 were eligible for inclusion. These studies were geographically diverse (28 countries). The pooled prevalence rate for overall elder abuse was 15·7% (95% CI 12·8-19·3). The pooled prevalence estimate was 11·6% (8·1-16·3) for psychological abuse, 6·8% (5·0-9·2) for financial abuse, 4·2% (2·1-8·1) for neglect, 2·6% (1·6-4·4) for physical abuse, and 0·9% (0·6-1·4) for sexual abuse. Meta-analysis of studies that included overall abuse revealed heterogeneity. Significant associations were found between overall prevalence estimates and sample size, income classification, and method of data collection, but not with gender. INTERPRETATION: Although robust prevalence studies are sparse in low-income and middle-income countries, elder abuse seems to affect one in six older adults worldwide, which is roughly 141 million people. Nonetheless, elder abuse is a neglected global public health priority, especially compared with other types of violence. FUNDING: Social Sciences and Humanities Research Council of Canada and the WHO Department of Ageing and Life Course.

The Forensic Lens: Bringing Elder Neglect Into Focus in the Emergency Department.

We present 2 case studies of older patients who were brought to the emergency department (ED) in severely debilitated states. Both presented with severe malnutrition, contractures, and decubitus ulcers, and were nonverbal, with histories of dementia and end-stage disease. Their primary caregivers, adult children, were uncooperative with Adult Protective Services and disregarded treatment recommendations. Although both elders had signs suspicious for neglect, a comprehensive review revealed many layers of complexity. We use these cases to illustrate an approach to the assessment of possible elder neglect in ED settings and how to intervene to ensure patient safety. We begin with a discussion of the differences between willful, unintentional, and unsubstantiated neglect by a caregiver and then describe when to suspect neglect by evaluating the elder, interviewing the caregiver and first responders, assessing the caregiver's ability to meet the elder's needs, and, if possible, obtaining medical history and information about the home care environment. These cases illustrate the importance of careful documentation in cases of suspected neglect to assist investigative agencies, reduce the risk of further harm, and improve patient outcomes.