Thursday, August 16, 2012

Elder Justice Comes of Age

Last June’s White House symposium on elder abuse was a watershed event. Delegates, many of whom had been advocating for decades for more federal involvement, were assured by high ranking administration officials that elder justice was a priority. Hosts, speakers, and delegates were near giddy in their fervor, and murmurs of “Is it for real?” wafted through the crowd.  

It coincided with something I’d been feeling for awhile: that elder abuse prevention had entered a new era. After years of making excuses for its protracted infancy, perhaps we were finally witnessing our field’s coming of age. 

Clearly, thinking about elder abuse had matured. “Elder justice” has emerged as the dominant new paradigm, offering a more expansive view. Defined by the framers of the Elder Justice Act as “the right to live free from abuse, neglect, and financial exploitation,” elder justice suggests that abuse isn’t just a matter of personal and interpersonal dysfunction, but rather, it’s about ensuring fairness, human rights, and equal access to resources and protections for all older adults. That’s a mighty big leap.

How this new perspective plays out remains to be seen. Hopefully, for starters, we’ll acknowledge that older adults are a distinct group with specific needs and circumstances rather than an add-on or “special population” within broader realms like victim rights or domestic violence. The “special” designation has led to plugging clients into services designed for other groups, which often aren’t a great fit. It has sometimes also meant buying into premises that don’t apply (e.g. that abuse is motivated by the drive for power and control, which domestic violence theory assumes) or pressuring victims into options they find unacceptable (e.g. reporting abusive family members to authorities in order to qualify for victim services). Defining our field through other disciplines’ lenses has forced us to make false choices (“elder abuse is ______” where the correct answer is: a woman’s issue, a hate crime, a caregiving issue, domestic violence, and so on, depending on whom you talk to).  That limit the options for helping victims.   

Pigeonholing elder abuse this way has had other consequences. It’s lead to conflicts within our ranks and kept us from gaining traction from an advocacy perspective. We’re remained politically marginalized, divided, disorganized, and powerless. 

Elder justice lets us start fresh and think bigger. It encourages us to rally our forces and find a common voice instead of arguing among ourselves about the “right” analyses. 

This expanded way of thinking has parallels in our research. The new “ecological” models of elder abuse that theorists have proposed acknowledge that personal, interpersonal, societal, and economic factors all play a part in abuse, thereby freeing us from the old dogmas about how situations should and shouldn’t be handled. They lend themselves to multifaceted and holistic solutions that include clinical, public health, and public policy interventions. 

Understandably, some may assume that elder justice just means ensuring that older people have access to the legal system. Clearly, that’s important. But, to a great extent, the legal system focuses on situations in which individuals‘ rights have already been violated, and elder justice can be much more. The California Elder Justice Coalition has adopted a proactive approach that I like to think of as “justice promotion.” It calls for taking affirmative steps to protect autonomy and self determination; ensure fair access to health, social, and legal services; thwart predation; and strengthen responses to abuse. It requires that we focus on capacity assessment and enhancement, ethical considerations in decision making, and safe advance directives. It includes consumer protections that focus on age-related vulnerabilities, keeping dangerous people out of the long-term care workforce, and heightening consciousness among those who serve older adults about high risk situations. 

Clearly, the federal commitment to elder justice displayed at the White House event marked a step forward. The Financial Consumer Protection Bureau, Administration on Aging, Social Security Administration, Department of Justice, and others, in partnership with financial institutions, have acknowledged that consumer protection is part of the elder justice equation by addressing predatory lending, scams, and other forms of exploitation. 

But there are countless other opportunities to promote elder justice. Consumer protections are needed in “consumer-driven” long term services and support (LTSS) programs. Focusing the elder justice lens on programs that transition Medicare and Medicaid beneficiaries into managed care or that provide in-home care requires that we establish strict screening and accountability measures for providers and that we develop realistic criteria for evaluating vulnerable consumers’ ability to choose and monitor their care.We know from recent research that the deficits that render people vulnerable can be subtle, and our network can play an important role in identifying potential problems and building in safeguards. Instructing LTSS providers in how to recognize deficits in decision-making capacity, asking them to be on the lookout for clients who have recently taken out reverse mortgages or who’ve been targeted by predators, and urging them to add  a few questions to assessment tools to identify risk could have a huge impact. 

Instituting these measures requires federal leadership. Let’s hope that our dynamic new federal leaders will connect the dots and see the possibilities for making elder justice an integral component of the service delivery system rather than as a field apart.