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Elder Abuse Workshop: Abuse and Neglect in Long-Term Care

Panel Presentations

Catherine Hawes — Detecting, Investigating and Resolving Elder Mistreatment in Residential LTC Facilities

Goals: To identify systems for detecting, investigating and resolving abuse after it is reported. Primary goals:

• Describe abuse reporting laws in all states.
• Conduct telephone survey of all “first responder” agencies.
• Conduct seven in-depth case studies.
• Identify smart practices.

Study Design: Focus on all types of residential care facilities (RCF).

Observations: This is hard research to do because colleagues don't want to talk to you about it. You need to think about how to support your staff during field studies. Some assume this elder population can self-report and protect themselves, but that is not true. This is a vulnerable population. Understaffing and inadequate training are major causes of abuse, but there is also a failure of political will to get proper regulations in place. The same problems persist and policy is not moving forward.

Conclusions: Preliminary findings:

• Problems with detection and investigations: there is little outreach and flawed intake with limited regulatory systems in most states.
• A growing problem is sex offenders, prisoners and people with persistent and severe mental illness who are placed in RCFs with frail elders.
• Practices and policies are dysfunctional, with underfunding of agencies and a lack of awareness of the views of field staff.
• Problems with detection and resolution: there is a difference in focus between APS and licensure that does not converge to the benefit of residents, and a limited and perplexing role of APS in several states. Police cooperation is variable, and prosecution is a major problem due to a failure to understand the residents and the setting, and a tendency to discount testimony in cases of people with dementia.
• There are some smart practices, including: 1) registries for all health care personnel, 2) criminal background checks for staff, 3) involvement of Attorney General's Medicaid Fraud Control Unit, and 4) ombudspersons.

Catherine Hawes — Developing Prevalence Measures of Elder Abuse in Residential LTC Settings

Goal: To develop and test methods of generating estimates of the prevalence of elder mistreatment in LTC settings and assess the feasibility and challenges involved in conducting a national study by:

• Developing valid operational definitions of elder mistreatment.
• Developing and testing the utility of various methods for estimating prevalence.
• Identifying potential resident, facility and staff risk factors for abuse.
• Using the findings to identify obstacles, recommend strategies and assess the feasibility of conducting a national prevalence study of elder mistreatment in LTC facilities.

Study Design:

• Test the definition in focus groups and individual interviews with 120 residents and 55 facility staff in two nursing homes and two RCFs.
• Test alternative methods for estimating abuse prevalence and determine which produces the most comprehensive reports of elder mistreatment through interviews with 780 cognitively intact residents and a randomized, anonymous sample of more than 350 direct-care staff on multiple shifts.

Conclusions: None yet.

Mark Lach — Resident-on-Resident Elder Mistreatment

Unexpected findings from a previous study: After completion of a large, community-based, longitudinal study to understand the epidemiology of police contact with community-dwelling older adults, some unexpected findings were:

• A substantial number (747) of the 2,322 participants were placed in nursing homes over the 13-year follow-up.
• Many police contacts with participants occurred after they were placed in the long-term care facility.
• These were overwhelmingly situations in which the police were called to intercede in resident-on-resident aggression.

Scope of the problem: Resident-on-resident elder mistreatment (RREM) is defined as negative and aggressive physical, sexual or verbal interactions between long-term care residents that would be construed as unwelcome by the recipient in a community setting and that have high potential to cause physical or psychological distress. There is little in the literature about RREM, but indirectly the literature indicates that behavior disturbances, such as those associated with dementia, are notorious provocateurs, and when patients with behavior disturbances and disinhibitions are commingled, it is asking for trouble. Clinical experience supports this observation as do two pilot studies that provide evidence for the phenomenon of RREM. Resident-on-resident elder mistreatment may be the most prevalent form of elder mistreatment, either inside or outside nursing homes.

Methodological challenges to studying RREM:

• Official reporting systems are subject to massive underreporting of cases, and there are nonstandard policies and practices across states.
• Resident informants (aggressors and victims) are often cognitively impaired, have visual and hearing impairments, and have incentives not to be truthful.
• Staff informants may avoid aggressive residents, and RREM often occurs and escalates specifically because staff is absent.
• Events may be ephemeral, infrequent or hidden.
• Researchers may be obligated to report events that they witness.

Next Steps:

• Need a prevalence study of RREM.
• Need to drill down on the range of various behaviors that constitute RREM.
• Need evidence-based intervention strategies to prevent RREM or at least avert poor outcomes if RREM cannot be prevented.

Janne Swearengen — Identifying and Monitoring Abuse and Neglect in Long-Term Care Facilities

Question: How do you evaluate whether poor care has become abuse or neglect?

Answer: Utilize available data to come to an informed conclusion.

Use of Data:

• Quality Indicator/Quality Measure (QI/QM) Data: QI/QM facility reports can identify facilities with very high rates of problem conditions in residents. QI/QM resident-level reports can identify residents with a specific clinical or functional problem or condition and identify patterns of problems in a single resident or across residents.
• Deficiency Data: Can indicate various citation levels (G,H,I,J,K,L) to identify substandard care, actual harm or immediate jeopardy.
• Observation and Interview Data: Observe resident care, appearance, staff-to-resident and staff-to-staff interaction. Interview resident, staff, family.

Putting It Together:

• Knowing how to interpret available data can lead to the identification of possible abuse or neglect.
• Intense and in-depth investigation can determine whether abuse and harm or neglect and harm have occurred.

Anne Montgomery, Lori Post, Susan Larsen — Research on Criminal Background Checks

I. Patient Safety and Abuse Prevention Act — Anne Montgomery

Improved screening of long-term care workers is needed to exclude individuals with abusive backgrounds. The Patient Safety and Abuse Prevention Act would be a good start in taking a proactive approach to screen out predators. In 2003, Congress authorized a three-year pilot study of background checks. States taking grant money were required to make improvements in background check systems and streamline the process among different state agencies, including doing more detailed checks. The study showed that although no single check worked, a multifaceted approach is effective. A total of 7,200 individuals were identified out of 200,000 checks. There is solid bipartisan support for the Act, which is endorsed by 41 states, numerous state attorneys general, and Medicaid Fraud Control Units. The bill is currently in committee in the House and Senate. More research is needed on costs and benefits of well-designed screening systems.

II. Centers for Medicare and Medicaid Services (CMS) Background Check Pilot Program Update – Susan Larsen

Program Purpose: To identify efficient, effective and economical procedures for conducting background checks. The pilot period ran from January 2005 to September 2007. The data are now being analyzed by an independent evaluator.

Study Design: CMS selected seven states to participate in the pilot. States could establish their own background check programs but had to meet specific requirements of the study. Most states built in sustainability to be able to continue the programs.

Pilot State Comments:

• All states agreed that conducting thorough background checks helps improve health care workforce quality.
• All states expressed concerns about the high cost of conducting state and FBI fingerprint-based background checks.

Lessons Learned/Best Practices:

• Begin with an incremental approach – first complete low-cost/fast turn-around checks and only spend money for expensive fingerprint-based checks for those applicants who clear the initial search.
• Capture and submit fingerprints electronically.
• Rap-back background check systems can improve effectiveness, efficiencies and cost.
• Background check time exemptions – some states reestablished exemptions after the pilot and do not require a new fingerprint-based check each time an employee changes jobs.
• Unintended consequences – when developing check processes be aware of potential unintended effects in reduced health care work force.

Three states delivered innovative, culturally sensitive and effective abuse prevention training programs.

III. Information Communication Technology for the Prevention of Abuse, Neglect, and Exploitation in Long-Term Care Settings - Lori Post

Problem: As more vulnerable elders require long-term care, there is no standardized system across agencies for preventing abuse, neglect and exploitation in long-term care facilities.

Partial Solution: Use information communication technology to standardize systems.

To answer the question of cost-effectiveness, a pilot study was conducted to make an economic analysis of abuse, neglect and exploitation.

Goal: Conduct a cost/benefit analysis for developing, maintaining and staffing the Michigan Program for Background Checks.

Study Design: Establish estimates of: 1) crime costs; 2) cost savings from crime prevention; 3) cost savings from training prevention, hierarchical system and system record retention; and 4) costs of developing, maintaining and staffing background check program and performing cost-benefit analysis.

Conclusion:

• Total savings from crime prevention efforts: $48,050,316.
• Total cost of instituting background check program: $9,568,707.
• Cost benefit for first year: $38,481,609.

Discussant, Nick Castle

Dr. Castle noted that there is very little in the literature on this topic, which is a developing area.

In terms of the institutional component, why do we find abuse? Staffing issues certainly contribute in an environment where staff workers earn $7/hour, work long and difficult hours, are often minorities, have stresses of their own at home, and then get abused by the residents. This fosters professional burnout, which leads to high turnover, which makes it necessary to bring in agency staff workers who don't have a relationship with the residents. This in turn leads to absenteeism and inadequate staffing — now we have a recipe for abuse. Solving the staff issue is a necessary first step, but it does not address the entire problem.

Another problem is the lack of definition of elder mistreatment. Where do you set the bar, low enough to use the definition as a screen? We have differences between QI and QM — what is this used for? There is a Web site where you can look up deficiency information, so if you bring up abuse, nursing homes don't want to talk about it. Terminology is also a problem — abuse, neglect, mistreatment, maltreatment — we are on a slippery slope and soon may be calling it "not being so nice to the elderly."

Dr. Castle stated that in his patient safety work he didn't see much about errors of omission or commission. Instead, the issues were scope and standardization. As to scope, how do you measure it in, for example, financial abuse? If a resident makes $10/month and you steal $1 you have stolen 10 percent of his income, even though you only took a dollar. How do we deal with standardization when residents' rights vary from state to state?

As to estimating prevalence, it is very difficult to get the right number of items for residents to comprehend the question. We ask nursing aides if they have ever seen, suspected or been told about abuse. With an N of 2,000, the data certainly show that abuse is occurring. Dr. Castle noted that he has personally walked in on an abuse situation that was clearly about to happen. He noted that his own children can push him to the limit — that is when he goes out to walk the dog. But how does a nursing aide take a "time-out?" What is a best practice here? We don't know yet.

Question/Answer/Comment Period

Dr. Maggie Baker asked the panel to comment on the incidence of sexual abuse in residential settings, specifically whether they think the numbers are higher than estimated. Dr. Lachs stated that hypersexual behavior in people with dementia is extremely common and reported often by nurses. Such residents will often impose themselves on many other residents, and most of this type of behavior in the long-term care setting is done by residents themselves, not sexual predators on staff. Ms. Swearengen added that residents' reports of sexual molestation are sometimes discounted by staff due to the belief that the residents are mentally or cognitively impaired. This raises the question of what kind of policies and procedures the facility has in place to respond to such resident concerns. Dr. Hawes reported that staff will sometimes normalize the sexual event, saying the resident did it to herself. This is not logical, but it is not always easy in this setting to discern what is normal sexual expression and what it not, which is why it is essential to have enough staff to observe and prevent problems.

Ms. Kathleen Quinn asked whether other states are developing background check programs. Ms. Larsen stated that not many other states, outside of those in the pilot, are doing it. Ms. Montgomery added that background checks are not within the scope of the legislation, and she opined that it is not clear that legislators would consider that part of the solution.

Ms. Fran Henry observed that currently the framework that drives elder maltreatment funding seems to come from the criminal justice area. She asked whether it would be valuable to come at the problem from a different perspective and frame the issue in terms of rights and responsibilities. Dr. Hawes suggested that this concept might not be grasped by a population in which two-thirds are cognitively impaired. Dr. Lachs stated that it is a constant struggle to decide how to frame the issue from a funding perspective and that in light of resident-to-resident abuse, framing the issue from an educational rather than punitive standpoint merited thought. Dr. Lachs added that epidemiologists direct resources according to attributable risks and opined that the risk in the long-term care setting is most likely living among violent residents, not violent staff. He said that if there were data to indicate this risk, it would drive the area to focus resources. Dr. Ron Acierno stressed the importance of focusing on the events first and defining the issue after getting accurate numbers. If the numbers demonstrate that the majority of cases are coming from resident-on-resident abuse, those data can be used to justify allocation of resources to that area. Dr. Hawes, noting the idea of cost-effectiveness, suggested that it is hard to reform the system where costs and benefits go differentially across settings and agencies. She added that staff-on-resident abuse does indeed exist, not necessarily because the staff person has a criminal background, but because the staff person is overly stressed. Dr. Acierno suggested that even without staff-to-resident abuse, resident-on-resident abuse might still account for a significant percentage of overall abuse.

Dr. Georgia Anetzberger stated that she and others in her local community had looked at the Patient Safety and Abuse Prevention Act and felt that they could not support it because: 1) it was based more on horror stories than reality, 2) it fostered a pervasive unwillingness to hire people with any sort of criminal background due to a fear of liability, and 3) a concern that over time the definition of criminal background could broaden to a greater application than warranted. Ms. Montgomery replied that the basis for the act is not horror stories but documented abusive staff and serial offenders, and it is necessary to ensure that they do not harm residents. The Act is a proven, non-costly intervention, and there is a moral responsibility to take action to keep those with certain criminal backgrounds out of the system. Resident-to-resident abuse is not implicated in the screening and is certainly a part of the larger picture, but the Act provides an opportunity to solve one area of the abuse problem as it relates to serial offenders. Ms. Naomi Karp asked whether there were any outcome data or before/after studies indicating that background checks lead to less abuse. Dr. Post said that efforts are being made to trace incident reports to licensing agencies, but it is too early to tell about outcomes. Ms. Larsen stated that CMS is looking at this aspect, too. She noted that it appears that heightened awareness leads to more accurate reporting and therefore incident reports actually increase. She added that through a centralized process to oversee all incident reports, a criminal background check was conducted on accused caregivers and a criminal background was rarely found.

Dr. Laura Mosqueda asked that the participants consider that neglect is more of a problem than abuse. Dr. Pamela Teaster suggested resident-on-resident and staff-on-resident abuse have the same effect on the victim. Dr. Post disagreed, saying that there is a greater negative impact on the victim when the abuser is someone the victim trusted. Ms. Jane Raymond asked whether anyone is studying family or other outsider abuse on residents. Dr. Lachs said that he has not planned to look at this, and he suggested the closest thing that he has seen in focus groups is in the situation of roommates where one resident has a lot of visitors and the other has none. This seems to provoke ill will that can lead to aggression. Dr. Hawes noted that in her research she is studying what happens to residents by asking residents themselves and staff. The issue may well be, in the case of abuse, that if the resident feels unsafe in the place where he or she lives, then the problem is not so much who is doing the abusing as the fact that it is occurring. The same is true of neglect, which leads to suffering that is just as painful for the resident. A part of the solution might be working on facility responsibility for various conflict situations. Dr. Lachs agreed that this is a big tent, and whether it is resident-on-resident or staff-on-resident, resources must be allocated.