Findings From an Elder Abuse Forensic Center

Abstract

Purpose: The first Elder Abuse Forensic Center (EAFC) in the United States was instituted in 2003. People from a variety of disciplines, including Adult Protective Services social workers, law enforcement, the district attorney's office, a medical response team, public guardian deputies, ombudsmen, mental health services, a victim advocate, and a domestic violence expert work cooperatively on cases of elder and dependent-adult mistreatment. Researchers conducted an assessment of the EAFC's impact on the efficiency and effectiveness of the collaboration. Design and Methods: Mixed quantitative and qualitative methods included statistical analysis of data from outcome surveys of EAFC collaborators and illustrative case studies developed from case files and structured interviews. Results: Mean survey scores evaluating the efficiency and effectiveness of the collaboration were significantly better than neutral responses. Case studies show efficient and effective case management through cooperation of the collaborating agencies. Survey results clearly support perceptions exemplified in case studies. Implications: An EAFC enhances the efficiency and effectiveness of those who address elder abuse in one community, which in turn leads to improved outcomes. Continued analysis to identify strengths, weaknesses, and cost effectiveness of the EAFC model is ongoing.

Marshalling the various resources needed to respond to elder abuse cases is both time consuming and complex. Serially contacting individuals who should be involved by phone precludes a well-integrated, optimal management strategy. If a meeting of the appropriate experts can be arranged, it may come too late to achieve a good outcome. In addition, the agencies mandated to address elder abuse are motivated by different goals and conditioned by different work cultures and experiences. In short, although interagency collaboration is crucial to successful management and prosecution of elder abuse cases, there are significant barriers to both coordination and cooperation. In an attempt to address these issues for cases involving the legal system, the University of California, Irvine, Program in Geriatrics implemented the nation's first Elder Abuse Forensic Center (EAFC) in Orange County, California, in May 2003. A demonstration project, this collaborative effort had a dual mission: to improve current practices for addressing elder and dependent-adult mistreatment locally while sharing expertise with colleagues across the country. At the EAFC, housed in the same building as Orange County Adult Protective Services (APS), experts from multiple disciplines work from a shared location and conduct biweekly case meetings. Table 1 lists the Orange County EAFC collaborative groups.

Studies have indicated the need for collaboration (Balaswamy, 2002; Blakely & Beall, 1991; Dolon & Hendricks, 1989; Quinn & Heisler, 2002), and elder abuse experts have called for multidisciplinary and interdisciplinary programs (Quinn & Heisler; Wolf & Donglin, 1999; Wolf & Pillemer, 1994). The EAFC was created to overcome barriers and to modify and expand a team approach: Key professionals meet frequently, and they dedicate time and effort not only to provide case consultation, but also to participate in case management activities as needed, seeing the case through to its conclusion. APS, the long-term care ombudsman, law enforcement, or the district attorney's office refer and present difficult elder mistreatment cases to the EAFC experts. Analysis of the EAFC is needed in order to determine its future role in Orange County and its potential as a model to be replicated in other jurisdictions.

A number of different methodologies have been employed in the evaluation of multidisciplinary, collaborative efforts (Onyskiw, Harrison, Spady, & McConnan, 1999; Rosenheck, Resnick, & Morrissey, 2003). Evaluators frequently survey the key players to assess perceptions about the success of the collaboration (Borum, Deane, Steadman, & Morrissey, 1998; Fawcett et al., 1997; Paine-Andrews et al., 1997; Polivka, Dresbach, Heimlich, & Elliott, 2001; Rosenheck et al.). In addition, exploratory and descriptive (or qualitative) methods are appropriate when assessing a program that is breaking new ground (Borum et al.; Cheadle et al., 2003). Some qualitative methods are interviews (Fawcett et al.; Paine-Andrews et al.; Rosenheck et al.) and case studies and reviews (Borum et al.; Cheadle et al.; Kegler & Wyatt, 2003). The case study or case review has long been used to highlight strengths and weaknesses in poorly understood systems and processes, and elder abuse research is well suited to this method (Collings, Bennett, & Hanzlick, 2000; Conlin, 1995; Gallagher, 2002; Tueth, 2000). This article employs a mix of these methods: It assesses the collaborators' satisfaction with the center by analyzing survey results (Part 1), and it illustrates the EAFC case-management process by presenting two typical cases of elder mistreatment that were referred to the center (Part 2). The EAFC serves both elder and dependent-adult populations.

Part 1: Surveys

Design and Methods

Researchers surveyed members of the EAFC team (collaborators) regarding cases referred to the center during a 1-year period. They distributed surveys specific to each referred case to all collaborators who were involved in the case (e.g., through consultation or investigation of facts related to the case). The collaborative groups (Table 1) surveyed include APS, the Vulnerable Adult Specialist Team (VAST; Mosqueda, Burnight, Liao, & Kemp, 2004), the district attorney's office, law enforcement (both sheriff's and police department investigators) and the public guardian's office. The research team developed survey instruments that included three satisfaction questions related to the collaborators' perceptions of the EAFC's effect on case management and outcomes (Figure 1). All survey respondents answered these three questions and were given the opportunity to write in comments related to each question. The surveys were also tailored to the respondent's functional area to collect specific process and outcome data for later analysis. This article focuses on these three satisfaction questions. A researcher reviewed draft surveys with collaborators for face validity and cognitive pretesting.

We analyzed de-identified survey data by using Microsoft® Access 2000 for the database; Statview (SAS Institute, 1998) for data summarization, t tests, and analysis of variance; and SAS v8.02 (SAS Institute, 1999) for Fisher exact tests. We assigned Likert responses values 1 through 5, with responses of 1 being the most negative and responses of 5 being the most positive. Respondents could have had two reasons for selecting a response of Don't know. If they did not know the EAFC was involved in the case (e.g., if a police investigator on a case was unaware of the referral), then their responses were excluded from the analysis. On the other hand, if respondents were unsure whether the EAFC was helpful (even though they were familiar with the center's role in the case), these Don't know answers were treated as neutral (3) responses.

Survey results are for 114 of 142 cases referred to the EAFC between November 18, 2003, and November 18, 2004. One case equates to a single alleged victim of mistreatment. Some cases referred during this period were not included in the study sample for the following reasons: open cases pending criminal investigation or prosecution (13), open cases pending investigation by the Public Guardian or other legal activities related to possible conservatorship (7), cases lost to follow up (2), or cases referred from other jurisdictions (6). Table 2 summarizes the alleged victims' demographic data.

Of the 114 cases, Orange County APS social workers investigated 104. APS workers investigate reports of mistreatment and conclude whether allegations are confirmed, inconclusive, or unfounded. A summary of the APS investigation findings for the study sample can be found in Table 3.

Table 4 contains data on the number of surveys collected and the respondents by group.

Survey Results

Three types of possible dependence were examined within the survey results: (a) Sample dependence due to individual cases being referred to multiple agencies, (b) Sample dependence due to individuals within agencies filling out more than one case survey, and (c) Dependence among the three questions.

We conducted a separate analysis of the survey results by using paired differences to remove possible effects of multiple agencies responding to surveys for individual cases (i.e., the samples were not independent because multiple surveys had a single case in common). These results were inconclusive, primarily due to the small number of overlapping cases available for most pairs of agencies.

We tested possible dependence of responses upon individuals filling out multiple surveys (for different cases) within each agency and found them to be not significant, indicating that the survey response for each case was independent of the individual filling out the survey.

We tested independence of the responses to the three satisfaction questions by using Fisher exact tests of the two-way contingency tables between the three pairs of responses (Q1 vs Q2, Q1 vs Q3, and Q2 vs Q3). The hypothesis of independence of response was rejected (p <.0001) for all three pairs, indicating that the responses were not independent from one question to the next. The recommended measure of association for larger contingency tables is Cramér's V (Siegel & Castellan, 1988), a measure of association between two variables. We calculated V for each pair of questions. V can take values from 0 to 1, with 1 showing the highest association. The results were: for Q1 versus Q2, V =.474, indicating moderate association; for Q1 versus Q3, V =.265 and for Q2 versus Q3, V =.307, both indicating weak association. The tendency for low scores on Q1 (more efficient) to be associated with low scores on Q2 (more effective) and Q3 (would not have reached the same conclusion) was not unexpected. The relatively low level of the association between responses indicates that inclusion of all three questions in the analysis is warranted.

We tabulated the survey results for each agency and used Fisher exact test to test for independence of response to group. All three questions showed significance (p <.0001), indicating that for each question, score was dependent on group.

We then used one-sample t tests (Box, Hunter, & Hunter, 1978) to test whether the average score of each group (see Figure 2) was significantly higher (better) than 3 (the neutral response). The results are summarized in Table 5.

Q1 and Q2 scores were significantly higher than the neutral score of 3 (just as efficient, just as effective) for all groups. For Q3, only VAST was significantly higher than the neutral score of 3. Law enforcement also scored higher, but not significantly so (p = 0.1606), and the other groups all had scores lower than 3 on Q3.

We then used one-way analysis of variance to test for differences in response to Q1, Q2, and Q3 between groups. For all three questions, the F value was significant (ps = 0.0191, 0.0288, and 0.0047, respectively) indicating that one or more groups had significantly different mean scores. We then ran Fisher's Protected Least Significant Difference paired comparison test on the individual pairs of means to identify significant pairwise differences. For Q1, VAST and district attorney scores were significantly higher than those of APS and the public guardian, but not significantly different from that of law enforcement. For Q2, the district attorney score was significantly higher than those of APS, VAST, and the public guardian, but not significantly different from that of law enforcement. For Q3, VAST and the district attorney scores were significantly higher than those of law enforcement and the public guardian, but not significantly different from that of APS.

In summary, the collaborative groups concurred that the EAFC enhances their efficiency and effectiveness (significant for 4 of 5 groups), and there were some significant differences between groups in the levels of their satisfaction.

Part 2: Case Studies

Design and Method

The University of California, Irvine, Institutional Review Board approved analyses of closed cases. Confidentiality was strictly enforced among EAFC team members. Verbal consent was obtained from EAFC collaborators who participated in taped, semi-structured interviews. Using process and outcome data from surveys, a researcher developed draft case-flow diagrams that were used to elicit further information about cases during individual interviews. All EAFC collaborators involved in a case selected for further study were interviewed. The research team developed case studies by consolidating information from EAFC case files, completed flow diagrams, and transcribed interviews. The case studies highlight the strengths of the team approach as well as some remaining challenges.

Case

L is a frail 83-year-old widow whose only son is deceased. L's only living relatives are an adult grandson, granddaughter, and ex-daughter-in-law. The grandson moved in with L after L's husband's death, but she later asked him to leave because he contributed nothing to the household, was allegedly abusing drugs, and wrecked a car she bought for him. He had also become verbally and physically abusive. The grandson refused to move out.

The first report of the grandson's abusive behavior came to APS from the ex-daughter-in-law (i.e., his mother); the second, from the domestic violence specialist referred by APS after the first report. There were also multiple reports to the police. APS confirmed physical and verbal abuse. As a result of her investigation, the APS worker advised L to take out restraining orders on all three of her relatives because of concerns about possible financial abuse. L refused to request a restraining order against the grandson, and the temporary order placed against the women was withdrawn after L hired an attorney to defend them. Feeling isolated, L sought support through her church. Her health was failing. She lost weight and was recovering from pneumonia when a visit from her minister triggered another argument with her grandson. After the minister left, her grandson slapped her so forcefully that she fell to the ground. L was taken to the hospital and treated for her injuries. L's former daughter-in-law reported the abuse, and all three women cooperated in a police investigation that led to the grandson's arrest. The suspect claimed that his grandmother was demented and had attacked him. At that time, L was 4′11″ and weighed 95 pounds; her grandson, 5′10″ and 175 pounds.

The arrest brought the case to the attention of a deputy district attorney, who referred it to the EAFC. In order to prosecute a felony violation of the California elder abuse statute, experts were required to (a) establish whether the physical abuse was of a force likely to produce great bodily injury, and (b) determine if the alleged victim was a reliable witness. APS workers explained the family dynamics to members of the EAFC team.

The EAFC scheduled a home visit by a geriatrician, a geropsychologist (both from VAST), and the APS social worker. After obtaining L's consent to examine her, the VAST professionals listened to L's account of her relationship and conflicts with her grandson—especially the incident under investigation. The geriatrician documented her physical condition, including gait and vision impairments. He found that she was underweight and depressed. Noting that her pneumonia at the time of the incident would have only added to her “baseline frailty,” the geriatrician concluded in his report that “My professional opinion with reasonable medical certainty is that the force exerted by the grandson in this alleged incident was sufficient to cause great bodily injury” (personal communication, December 9, 2004). The geropsychologist elicited information about L's social history and family support system and assessed her psychological and mental status. He found that although L had mild cognitive impairment, “she is a credible historian and can give a good accounting of what occurred to her” (personal communication, December 7, 2004). He also noted her anxiety, depression, and dependent personality.

In the following weeks, the APS worker coordinated people from agencies that provide emotional support (including herself, the victim advocate from the Victim Witness Assistance Program, and a domestic violence social worker with advanced training in gerontology). Meanwhile, L's former daughter-in-law and granddaughter pressured her to recant the testimony implicating her grandson. L wavered, but the coordinated group of social support professionals provided reassurance. At the preliminary hearing, the VAST geriatrician testified that the alleged assault was characterized by “force likely to produce great bodily harm.” L provided details of the assault; her testimony was both credible and crucial. The suspect was held over for trial. Later, he pled guilty to both felony and misdemeanor charges, thus avoiding a trial. He was released on probation and served with a restraining order.

The EAFC's interdisciplinary strategizing and implementation of their plan was critical to the successful forensic (criminal justice) outcome of this case. The geriatrician provided evidence integral to the prosecution of the felony; the psychologist gave the go ahead for calling the victim as the only witness to the event other than the suspect. Through the coordinated efforts of professionals, the victim received emotional support during a difficult process. Team members' comments support the survey findings regarding their satisfaction with the EAFC. One respondent said, “This is a case of collaboration working well. Without the EAFC, it would have been [the domestic violence social worker] and APS going in circles.” Another stated, “We wouldn't have been able to prove the elements required for a felony charge without the expert witness.”

However, although there were no further APS reports, the EAFC team remained concerned about L's vulnerability. In fact, a family member called the victim advocate to report that the granddaughter had moved in with L, and the domestic violence social worker reported that the granddaughter had convinced L to refuse further counseling or assistance from their agency. The EAFC's limited ability to help the victim is also clearly illustrated by L's case. Collaborators were all concerned about her vulnerability to abuse by her female relatives. One respondent said, “There's still not really a resolution. This just went from one abuser to another.” Another stated, “We only have forensic outcomes. I don't know how she's doing at all.” Yet another collaborator said, “What we're missing is service to the victim.” A final respondent remarked, “The victim is still unsafe, but it's her family. She has no one else in her life.”

Case

E is a 95-year-old woman with advanced peripheral vascular disease and arthritis, no longer able to walk, being cared for by her daughter, D, at home. E accused D of both verbal and physical abuse that included moving her around the house by dragging her in a rug. E's injuries included skin tears, bruises, and rug burns. D had promised her mother that she would take care of her at home until her death, but a combination of D's “anger issue” and D's own disability from asthma contributed to the abusive behavior. The APS worker enlisted the support of a sheriff's investigator from the EAFC, and they jointly investigated the case in a home visit. As a result, with E's agreement, E was temporarily placed in a board-and-care facility. There was a concern that D would bring her mother home again to fulfill her promise to care for her at home.

The sheriff's investigator referred the case to the EAFC team to consider the best course of action—especially the possibility of prosecuting D. The APS worker advised the team that D's asthma prevented her from carrying her mother and, because she had no equipment, she used the rug to transfer E from one room to another. In the APS worker's judgment, although D's behavior was abusive, she was also an “overwhelmed caregiver” in need of permission to go back on her promise to her mother. The APS worker believed that the police investigation had alerted the daughter to the seriousness of her situation and that she would not bring her mother home again.

The geriatrician did not participate in the home visit and was not provided with medical evidence that supported a diagnosis of physical abuse. The deputy district attorney noted that both APS and law enforcement had observed that E was a “difficult” person and that this would expose her as an unsympathetic victim in a jury trial. Law enforcement was concerned about both the lack of well-documented medical evidence and their ability to prove D's intent to do harm. For these reasons, as well as because D was not a caregiver for anyone else, the district attorney advised that the interests of justice would not be served by prosecution. The ombudsman was apprised of the situation and the concern that E not be released to D's care. The police investigation was closed.

In follow-up interviews, the team members concurred that a good result had been achieved: The victim was safe. There was concern that an alleged abuser was not brought to justice and that the victim's wishes to remain at home were not honored. However, the team members agreed that it was not practical to prosecute, and that making this decision early in the case with all available information and in consultation with the team was the most efficient course.

Implication

Survey results indicated that all collaborating groups were enthusiastic about the enhanced efficiency (Q1) and effectiveness (Q2) they were able to achieve through working together with the EAFC to manage and process abuse cases. Mean scores on these two questions were significantly better than a neutral response, with fewer than 20 negative responses to Q1 or Q2 (somewhat or much less efficient or effective) out of more than 200 surveys. The moderate association of these two questions was clearly explained in survey and interview comments: Frequent meetings and coordinated planning facilitate quick response to abuse cases. A timely response is often the most effective response for victim safety, preservation of evidence, and apprehension of the perpetrator. Also, when the team directs and coordinates investigative resources from APS, law enforcement, the district attorney's office, and the public guardian, efforts are focused appropriately and duplicate activities are avoided.

A qualitative analysis of themes from written survey comments related to efficiency and effectiveness indicated that APS workers valued highly the availability of the VAST professionals to determine the alleged victim's capacity to make decisions or to testify about events. Other survey comments pointed to the efficiencies attributable to the EAFC's frequent meetings and multidisciplinary collaborative relationships. Those mentioned most often were readily available information; prompt, coordinated interventions; expedited communications between and among groups; better communications with alleged victims and their families; and early decisions about whether to prosecute a case. Survey comments related to effectiveness praised the better quality of information available as well as case plans and outcomes achieved in a collaborative setting. The availability of VAST clinicians to determine victims' needs for medical or psychological services, to assess medical evidence of abuse, or to interact with the victims' physicians was also considered crucial to effective case processing. APS workers were grateful for better access to information on legal, law enforcement, and conservatorship matters. Law enforcement and the district attorney appreciated the forum for working together to plan and coordinate better criminal investigations, and the district attorney indicated several cases that would likely have escaped prosecution if not for their referral to the EAFC.

Although responses to Q3 (Would the case have reached the same conclusion without the EAFC?) were more neutral than positive, they also indicated the EAFC's usefulness. Those who work in the field of elder mistreatment know that it is difficult to achieve a good outcome, and choices, such as those made in the case studies, have mixed results. Making a positive difference in the lives of victims is an elusive, though worthwhile, goal. The collaborators responded that better outcomes attributable to the EAFC occurred in nearly 50% of cases, indicating a noteworthy beneficial effect. Of the group responses to Q3, the district attorney was the most positive on average, and some preliminary outcome data illustrate why. Thirteen cases referred during the study period remained in criminal proceedings at the time of this analysis, and six misdemeanor and nine felony convictions had already resulted from the cases in the study sample. This represents a significant increase in elder mistreatment prosecutions compared to years prior to the institution of the EAFC.

This study is limited by the subjective nature of the survey responses, and there is a likely enhancement of positive responses due to the halo effect of favorable relationships developed in the course of working on cases.

Although the forensic emphasis of the EAFC is needed, it may not go far enough. Many cases, such as the two presented here, illustrate family dynamics that often interfere with successful prosecution or that perpetuate the risk of abuse even though a perpetrator is convicted. The first case shows how elders may remain vulnerable and resist help that protects them from potential abusers, because this is their right as autonomous adults. The second case shows that the safest solution may still fail to satisfy the victim's wishes. Broader, more creative, victim-centered remedies that preserve the self-determination and autonomy of older adults are needed.

The research team continues to follow up on cases and expand analyses to further identify strengths and weaknesses of the EAFC. Methods for assessing cost effectiveness are needed. Nevertheless, the cooperative interagency relationships, the positive survey responses, and the improved case conclusions indicate that other jurisdictions may benefit from an elder abuse forensic center model.

References