Mental Health Services for Vulnerable Elders

Many of us in California were disheartened to learn that as part of Governor Schwarzenegger’s plan to balance the budget, he wants to raid Proposition 63 funds. Prop 63 was a 2004 ballot initiative that imposed a 1% tax on millionaires to fund mental health services. The governor wants to use the funds to pay for existing programs instead of developing new services, something the initiative specifically forbids.

But according to Senate President pro Tem Darrell Steinberg, who championed Prop 63, the governor’s plan is "a non-starter." As a ballot initiative, any changes to Prop 63 have to be approved by the voters, and since the bill passed by a comfortable margin in 2004, that’s not likely to happen.

Those of us on the Archstone Advocacy Work Group hope that's the case. The group consists of reps from agencies that receive funds from the Archstone Foundation as part of its Elder Abuse Initiative. After hearing that few advocates for the elderly were participating in statewide Prop 63 “stakeholders” meetings, which set priorities for how the new money can be used, or applying for funds, our group produced a Fact Sheet that describes vulnerable elders’ mental health service needs and suggests ways that elder advocates can get involved.

The Fact Sheet is posted on the Web site of the Center on Excellence in Elder Abuse and Neglect. See Prop 63 and Elder Abuse.

Readers are welcome to use the Fact Sheet in California and beyond.

Community Colleges, An Untapped Resource for Preventing Elder Abuse

For the last three years, I’ve been working with faculty at City College of San Francisco (CCSF), under a grant from the Archstone Foundation, to develop a course in elder abuse prevention for students in the paramedic, health care interpreter, and community health worker programs. Along with my colleagues consultant Eileen Goldman and CCSF instructor Robin Roth, we started out teaching Health 9A Elder Abuse as a traditional course. Later, we modified it into a “computer enhanced” class using online reading assignments, forums, and interactive exercises to supplement the classroom activities. Beginning in March, 2009, I’ll be teaching it as a fully online course. For more information, see Health 9A: Elder Abuse.

I’m really enjoying my teaching stint at CCSF and strongly encourage others to get involved with the community colleges in their areas. It’s a great way to reach allied health professionals. According to an article in the magazine of the Faculty Association of California Community Colleges, California’s community colleges “credential 80% of the state’s firefighters, law enforcement officers, and emergency medical technicians; and 70% of nurses.” Specifically, CCSF prepares students for careers as medical assistants, certified nursing assistants, licensed vocational nurses, registered nurses, nutrition assistants, diagnostic medical imaging technicians, radiology technicians, cardiovascular technicians, EKG technicians, pharmacy technicians, and dental assistants. They also offer programs in the administration of justice, trauma, and drug and alcohol counseling. The schools work closely with their local communities to meet workforce shortages and to make sure that they’re preparing students for the real world. Which also means that they place a strong emphasis on diversity and cultural competence. Truly an untapped resource.

Guardianship Under Assault

Indictments of guardianship and guardians are flying fast and furiously these days on Web sites and blogs:

A new site, operated by a group calling itself the National Association to Stop Guardian Abuse, explains guardianship this way:

"At present, it operates to ensnare the most vulnerable people in a larger and larger trawling net, now including those merely physically "incapacitated"! It has become a feeding trough for unethical lawyers and other "fiduciaries" appointed by the courts to protect, but many of whom become nothing more than predators."

Another, called “Abusive Guardianships of the Elderly,” exhorts readers to share their stories:

“Has someone you love been victimized by the guardianship racket? Please share your experience. We must look to each other for ideas and support if we are to stop the blatant exploitation our elderly and infirm suffer at the hands of the system and the law who is charged to protect them.”

And, in a recent response to my Feb 12, 2007 posting “Feel Good Laws or Real Reform?” about California’s conservatorship reform package, a respondent named “Sherry” had this to say:

"(The vulnerable) have become the prey for a predatory and lucrative guardianship/ conservatorship industry. In case after case, the ward's estate is pilfered by the guardian, while the ward is isolated in a nursing home against his will, not allowed contact by family members or friends, and eventually dies, bewildered and alone, all with the blessing of the court!"

Some of these critics have personal tales to tell. I don’t doubt their stories or their motives. We all know that abuses happen more often than they should. And I can think of nothing more disturbing than when “helping professionals” exploit those they’re charged to serve. Whether the offenders work for public agencies; private, non-profits; or they’re in private practice; their misdeeds leave colleagues feeling betrayed and demoralized. It casts a shadow on our field and undermines the public’s trust. But the wholesale vilification of the system and those involved, which seems to be accelerating, is deeply troubling.

The censure isn’t just coming from the public. Among professionals too there’s a tendency to impugn “the system” rather than those who corrupt it. And there’s been far too little meaningful discussion about how to fix problems, promote promising practices, offer safe alternatives, and provide the public with accurate and balanced information.

Guardianship was created to protect the vulnerable and prevent abuse and neglect. For the most part, that’s what it does. California’s Administrative Offices of the Court recently released a report, Effective Court Practice for Abused Elders, which includes the findings of a file review of conservatorships. In over 70% of the petitions filed in one county, there were allegations, suspicions by court investigators, or other indications of abuse or neglect by family members, neighbors, businesses, and others. (The report, which was funded by the Archstone Foundation, is available on line at Effective Court Practice.

The stories behind these cases—estates that have been saved and predators who’ve been thwarted--don’t get much attention or make headlines. They are, however, well known to those of us who have seen the system at its best. I admit that many of us in the San Francisco Bay Area are a bit biased as we have some of the best courts, attorneys, and professional guardians around. When I directed the San Francisco Consortium for Elder Abuse Prevention, members of our multidisciplinary team often breathed a collective sigh of relief when a particularly thorny abuse case was referred to the court, where we knew it would be rigorously reviewed.

So how do we go about restoring trust? An important first step, I believe, is to shed light on the system so that we fully understand and can explain both its strengths and shortcomings. To date, we lack such basic information as how many guardianships there are nationally, why they’re established, and how well they’re doing what they’re supposed to.

We also need to dispel damaging and persistent myths and misperceptions. As the quotes above suggest, there’s widespread belief that anyone who has a mental impairment can be placed under guardianship and that courts go “trawling’ for wards. We need to get the word out that while nearly 50% of people over 85 suffer from cognitive impairments, only a small proportion need guardianships. We also need to inform both professionals and the public about who initiates guardianships (not courts), and why—often, it’s because less restrictive legal devices like powers of attorney or trusts have been misused or when APS, police, or emergency personnel discover gravely disabled elders living in horrible conditions as a result of dementias. Once appointed, guardians can remove wards’ assets from wrongdoers’ control, initiate lawsuits to recover misappropriated assets or property, evict wrongdoers from elders’ residences, purchase needed services, authorize medical treatment, and arrange for elders to live in safe places.

Probably the most common complaint against guardianship is that it’s overly restrictive. For that reason, it’s considered the option of last resort. But as I pointed out in “Feel Good Laws or Real Reform?” the fact is, there are few alternatives. Those that are typically cited -- case management, daily money management, powers of attorney, and other advance directives--aren’t really alternatives. They might have circumvented the need for guardianship had they been implemented prior to the onset of incapacity; but once someone loses capacity, it’s too late to execute advance directives, and many social service providers can’t accept clients who are incapable of giving informed consent.

The few options available for those who have already lost capacity include representative payeeship, limited guardianships, and the appointment of surrogate decision makers on a one-shot or temporary basis. Rep payeeship, which can protect clients whose primary income is from public benefits, can be put in place for those who are unwilling or unable to consent. Under Georgia’s Health Care Placement Decision-Maker for An Adult Act, any person can petition the court to authorize placements in long-term care facilities. A few states have “protective custody,” which allows for vulnerable adults to be hospitalized for a few days when they lack capacity to consent to protective services and are in imminent danger or at risk of death. While in “custody,” their capacity and protective service needs are carefully assessed.

California has explored several options, which I discussed in my earlier posting. But for the most part, they’re untested, and many aren’t being used. Some, like Probate Code section 2952, which allows public guardians to freeze the assets of vulnerable elders when there’s cause to believe that they’ve been the victims of financial abuse, are coming into use gradually. Although the statute was enacted years ago, most counties continued to rely on temporary conservatorships (t-cons) in these circumstances. It appears that PGs have been using section 2952 more since the passage last year of a new law that requires courts to complete full investigations of t-cons. California also has a protective custody law, Welfare & Institutions Code Section 15703 - 15705.40, which has only been adopted in a few counties.

Clearly, these options need to be carefully scrutinized. For years, I’ve been calling for a statewide group to identify policy needs and perhaps more importantly, track what laws have been implemented, why some haven’t, how they’re working, and if they need tinkering.

As the population ages, more people are going to need guardianships and safe alternatives. It’s time to seriously address the problems in the system, explore alternatives, dispel myths, and earn the public’s trust and confidence. The longer we wait, the harder it’s going to be to turn things around.

The Year in Elder Abuse Prevention

The journalistic tradition of year-end “news roundups” provides an excellent ruse for cleaning out my file of items I didn’t get to last year. Here are a few:

Under the rubric of “Congratulations and Transitions”:

Marie Theresa Connolly left her post at the Department of Justice to accept a fellowship at the Woodrow Wilson International Center for Scholars, where she’ll be writing a book on elder abuse. She is one of 21 fellows at the “quasi-federal entity with an ongoing mission of linking the worlds of ideas and policy.” I’m thrilled for M.T. who’s been doing groundbreaking work in the field for years. She is an expert in prosecuting abuse in nursing homes and played a leading role in crafting the Elder Justice Act while on loan from DOJ to the Senate Special Committee on Aging. She also spearheaded efforts to advance medical forensics in elder abuse, organizing the first national symposium on the issue and subsequent research. Fortunately, she plans to continue working in the field of elder justice in some capacity when she’s done. Here's what she had to say about the book:

"Despite broad bipartisan support, the Elder Justice Act, first introduced in 2002 and in every Congress since, remains unenacted in the face of chronically insufficient resources, data, infrastructure, expertise, training and public awareness. As a result of this paralysis, my goal is to write an accessible book about elder abuse that will propel change by raising public awareness about the problem through the stories of real people, and serve as a resource and catalyst for policy-makers, researchers, practitioners and the public."

M.T. will be presenting “Emerging from Obscurity: Elder Abuse's Slow Journey Toward the National Agenda” at the Elder Abuse: Medical Abuse and Multidisciplinary Aspects conference sponsored by the University of California, Irvine on February 11-12. You can also hear her talk about the book online at M.T. Connolly

Forensic psychiatrist Bennett Blum was ordained as a rabbi by the Academy for Jewish Religion, an “alternative-minded trans-denominational rabbinical school” in L.A. As an expert in cognitive assessment and undue influence, Bennett often testifies in court cases; it was a case involving a rabbi, in which he was asked to base his legal argument on Jewish sources, that he got to thinking about how ancient rabbinic views on deceptive and manipulative practices applied. He went on to write an article on the subject, which led others to "use Talmudic perspective for formulating their arguments." He is also hoping to start a non-profit organization to foster collaboration between clergy and social service providers. What sets his approach apart from most faith-based programs is that he hopes to engage clergy not simply as gatekeepers to get congregants into the legal and social service systems, but rather, to appeal to them to draw from the wisdom of their traditions to teach, guide, and heal. For more on Bennett, see undue influence.

Family justice center maven and former San Diego District Attorney Casey Gwinn is the new CEO of San Diego’s YWCA. Casey founded San Diego’s Family Justice Center, a “one-stop shop” for domestic violence victims, which serves as the prototype for centers across the U.S., Canada, Mexico, and England and the National/International Family Justice Center Alliance, which provides technical assistance to centers worldwide. A few years ago, the San Diego Center began serving victims of elder abuse with support from the Archstone Foundation. Casey will continue to be involved with the Alliance. In November, he was one of three community leaders awarded The California Wellness Foundation’s 15th annual California Peace Prize.

Heidi Li has replaced Mary Twomey, who, in 2000, replaced me as Director of the San Francisco Consortium for Elder Abuse Prevention (Mary is the new co-director of the Elder Abuse Forensic Center of Orange County). Heidi, a lawyer, has a background in fair housing and anti-predatory lending consumer protection. She was a founding co-director of Housing and Economic Rights Advocates (HERA), a statewide non-profit legal service and advocacy organization, and previously worked as a senior staff attorney for the Fair Housing Law Project (FHLP) where she helped develop San Jose’s predatory lending screening clinic. Her background in law advocacy is sure to be a boon to the Consortium.

And, more on the advocacy front:

The Elder Justice Act continues to languish in Congress, which supporters blame on Congress’ partisanship, its preoccupation with Iraq, the difficulty of passing a stand-alone bill, and the fact that the wide-ranging bill spans multiple committee jurisdictions, which means that multiple leaders have to vet the bill, which takes time. On the bright side, there doesn’t seem to be much opposition. Rahm Emanuel, the bill’s main sponsor in the House, has said he’s hoping to get pieces of the bill included in other legislation. The bill provides for: elder justice offices in the U.S. Departments of Justice and Health and Human Services, $400 million for state adult protective services over four years, creating a federal coordinating committee, forensic centers, and penalties for nursing homes for failure to report crimes quickly. Emanuel's bill also would require the attorney general to develop a plan for prosecuting elder abuse cases and provide grants to assist state and local prosecutors.

Another bill I’m following is the Restitution for Victims of Crime Act of 2007, which would improve the collection of victim restitution and criminal fines (which fund victim services and compensation). The bill was introduced in response to a GAO report that estimated federal criminal debt at $46 billion, most of which is owed to victims. The bill also removes barriers to collecting restitution and helps federal prosecutors prevent criminal defendants from spending or hiding their assets by setting up pre-conviction procedures. The bill has strong support from such prominent and far ranging advocates as the National Center for Victims of Crime, Mothers Against Drunk Driving, and the National Coalition Against Domestic Violence.

The problem of restitution was explored in the recently released Repaying Debts, which was produced by the Council of State Governments. The report assumes a wide-angle view of the problem, emphasizing, for example, that when prisoners are released, many are so far in debt to myriad entities that paying what they owe is virtually impossible. Those responsible for collection, which include probation departments, courts, attorney generals’ offices, and child support enforcement offices, operate at cross purposes, and victims and children are usually at the end of the queue for getting what they’re owed. The report calls for cleaning up the entire system, which includes providing for a single agency to coordinate repayment, set priorities, and create more opportunities for criminals to repay what they owe through work and community service programs. See Repaying Debts.

And in California, several important new laws go into effect this year:

• Cal Senate Bill 611 allows judges to freeze assets in cases of financial abuse until victims’ claims are resolved so that defendants cannot spend or hide them before the case is decided. The legislation was sponsored by California Advocates for Nursing Home Reform (CANHR), AARP, and the California Alliance for Retired Americans.

• Cal Assembly Bill 1298 requires that California residents be notified when their electronic medical information or health insurance information has been exposed, thereby raising their risk of identity theft. The new law expands on California's earlier data-breach notification law, the first of its kind in the country, which inspired similar laws in more than 40 states. The 2003 law only covered financial information, with the new law coming in response to a report on medical identity theft issued by San Diego’s non-profit World Privacy Forum in 2006. The report revealed that a quarter of a million people per year are victims of this crime.

Comings, Goings, and Congratulations

Congratulations and heartfelt best wishes to Mary Twomey, who will be leaving her job as Director of the San Francisco Consortium for Elder Abuse Prevention at the Institute on Aging to become co-director, along with Laura Mosqueda, and northern California liaison of U.C. Irvine's Center of Excellence in Elder Abuse and Neglect.

Obviously I've had a strong interest in Mary's work since she took over as the Consortium's director when I left in 2000. I think it's only natural, when someone takes over a job you've had for 16 years, to have a certain amount of ambivalence. Of course you want them to do well and carry on your work. But there's also a nagging fear that they'll discover your skeletons or shortcomings; or worse, outshine you.

But watching Mary take the Consortium in new and exciting directions has been wonderful to watch. She's led the program with grace, skill, and panache. Under her guidance and with the help of IOA staffers Dana Smith, Melissa Anderson, and Tessa ten Tusscher, the Consortium has made remarkable strides. What was a fledgling support group and counseling program when I left is now an integral component of the IOA's geriatric psychology training program, which means that every participant in the program receives training in working with elder abuse victims. They currently have 20 marriage and family therapist interns, practicum students, and a post-doc. Plans are underway to secure funding for an elder abuse forensic center, which will be modeled on UC Irvine's. The Irvine Center is staffed by legal, medical, social services, and law enforcement professionals who review abuse cases, develop care plans, conduct in-home medical and mental status evaluations and evidentiary investigations, and provide training and consultation.

Mary's new job will involve working with other projects funded by the Archstone Foundation around the state, overseeing technical assistance to grantees, and helping the center provide leadership in statewide advocacy.

Of course I'm looking forward to seeing who fills "our" job next and will keep you posted.

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Congratulations too to Lori Jervis, Assistant professor of American Indian and Alaska Native Programs at the University of Colorado, Denver, for being awarded a grant from the National Institute on Aging for a pilot study on the mistreatment of American Indian and Alaska Native (AI/AN) elders. The goal is to lay the groundwork for studying the prevalence/incidence of mistreatment among rural and urban Native elders by exploring alternative methods and proposing recommendations for future research that are both scientific and "grounded in local realities."

They'll be assembling two groups to guide the project: 1) an interdisciplinary team of researchers with expertise in AI/AN communities and a track record in conducting epidemiological studies with the population, and 2) a culturally and geographically diverse panel of Community Experts with backgrounds in Native elder advocacy and abuse prevention. I'm pleased to have been asked to serve on the latter.

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Earlier this week, the Administration on Aging announced grants to operate the National Center for Elder Abuse. The National Committee for the Prevention of Elder Abuse will oversee NCEA's multidisciplinary efforts, the National Adult Protective Services Association will oversee training, and the University of Delaware will serve as co-manager.

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As many of you know, I've had a strong interest in restorative justice approaches to preventing elder abuse. So, I was intrigued and pleased to learn that Arlene Groh, Elder Abuse Restorative Justice Resource Consultant for the Elder Abuse Response Team in Waterloo, Ontario, spent the Second World Elder Abuse Awareness Day in Busan, Korea, giving a workshop on her work. Participants came from all over the country and included elders, academics, experts in family violence, and representative from Elder Abuse counseling centers across the country. The event was hosted by the Korean Information Network for the Prevention of Elder Abuse (KINPEA) in collaboration with the administration of Busan and the Metropolitan City National Health Insurance Corporation, which is playing a leading role in creating a long-term care insurance service in Korea.

Arlene's visit was at the invitation of Dr. Dong Hee Han, who has a doctorate in elder abuse and is attempting to make changes in how elder abuse is addressed in Korea by looking at a new definition of filial piety, connecting isolated seniors with "cyberspace families," and working with elderly prostitutes.

Archstone Foundation Creates Community of Contractors

Last month I was at the second “convening” of Archstone Foundation grantees, representatives from projects funded under the foundation’s 5-year, $8 million Elder Abuse and Neglect Initiative.

I’m not actually a grantee but consult on two training projects. Along with my colleague Eileen Goldman, I’m helping faculty at San Francisco's City College develop a curriculum for fire fighters, paramedics and emergency medical technicians, which will eventually be integrated into the school’s curriculum and made available on-line. The other is an advanced training curriculum on self-neglect for APS workers being developed by San Diego State. Training is one of three priority areas for Archstone; other grantees are targeting dental students (UCLA) and clergy (Santa Clara County).

Another priority is innovative projects, with the largest grant going to the University of California, Irvine for a Center of Excellence on elder abuse, an expansion of the University’s elder abuse forensics center, which has been around since 2003. The center, the first in the country to focus on elder abuse, does evidentiary investigations and interviews, runs two multidisciplinary teams; and provides education, technical assistance and consultation. They also do research and just completed a study on bruises that provides baseline data on “natural” bruising that can serve as the basis for evaluating the non-natural kind. Hopefully, it will help prosecutors and others respond to the ubiquitous “she fell” or “she’s on Coumadin” defenses. Another study is looking at the rates of pressure ulcers in nursing homes, which will be used to help identify substandard care, and a third study is looking at California’s APS data collection system (which, not surprisingly, is not getting rave reviews). Study results are available on the Center’s website at.www.centeronelderabuse.org.

The forensic center model is being replicated at the University of Southern California under another grant, and my former employer, the Consortium for Elder Abuse Prevention at the San Francisco Institute on Aging has a grant for what Consortium Director Mary Twomey has characterized as the “poor man’s forensics center.” It provides free geriatric assessments that focus on capacity and undue influence to community agencies and has organized a network of experts to provide on-line and telephone consultation. The center may lack the panache of the south California forensics centers, but fills a critical community need and a viable alternative to other communities.

Another large grant was awarded to add an elder abuse component to San Diego’s Family Justice Center in collaboration with the San Diego District Attorney’s Office. I first learned about the SD justice center last year in Waterloo, Ontario, where I sat in on at a meeting to discuss plans for adding an elder abuse component to their family justice center. Casey Gwinn, director of the SD center, had just been in town and caused quite a stir. Unlike the SD center, which operates out of a downtown high-rise, the Waterloo center is in a home-like setting. Still, the concept is the same: co-locating police, prosecutors, forensic experts, and victim advocates from public and private, non-profit agencies to provide “one-stop shopping” and “wraparound” services. Casey is also a pivotal player in a national project (US Office on Violence Against Women) to replicate the justice center model, an initiative he recently described on Oprah.

Other projects focus on the sticky issues of predatory lending (Council on Aging Silicon Valley) and investment fraud (WISE Senior Services of Santa Monica). The predatory lending issue has been particularly close to my heart ever since the Leadership Group of the San Francisco Consortium’s WE ARE FAMILY African American outreach project discovered over a decade ago that African American elders in SF were being targeted by predatory lenders working in cahoots with home repair companies to get them to take out loans to fix up homes damaged during the ‘89 earthquake. The tactics used to take homes and get them back have become much more sophisticated since then, and the Silicon Valley project is impressive. Project personnel are trying to figure out how to get to vulnerable seniors as early as possible.

California’s Administrative Offices of the Courts is doing a statewide survey of court practices in elder abuse. They’re focusing on a few courts, which include Alameda County’s Elder Court, which has gotten a lot of press lately. The court, under the guidance of Judge Julie Conger, has a case manager, a separate docket for elders, and has been using California’s elder abuse restraining order extensively. The orders, which differ from domestic violence orders (which are also used in elder abuse cases)can also offer protection against financial abuse and abuse by non-family members, and are one of several practices the AOC is looking at. The idea for the elder abuse order came from San Francisco’s MDT and was sheparded through the State Assembly by Consortium member Judy Hitchcock of Legal Assistance to the Elderly.

Several other grants were awarded to start specialized MDTs. The Area Agency on Aging Serving Napa and Solano Counties, and the Elder Financial Protection Network of Novato started financial abuse specialist teams (FASTs) and the Riverside County Regional Medical Center is developing an assessment team to focus on self-neglect. Other teams have been started by San Bernardino’s Arrowhead Regional Medical Center and the City of Long Beach.

I’ve been to dozens of contractors’ meetings and professional forums over the years, but what impresses me about the Archstone project is the tone. There’s a strong emphasis on creating a “community of contractors.” The group meets once a month by phone and has convenings twice a year for updates and to solicit feedback. Other unique features are a technical assistance component, provided by the Center on Excellence, which draws from its stable of in-house staff and community consultants, and the involvement of a research/evaluation firm. Also noteworthy is that the Archstone team includes experts. The foundation has been sponsoring innovative elder abuse prevention projects since the early 1990s, and Mary Ellen Kullman, the foundation’s vice president, has been active on the national scene, sponsoring and participating in events from the beginning. Laura Giles, the lead contract officer for the initiative previously worked for the Irvine forensics center. So far, the contractors have been pretty candid, a refreshing change from your standard dog-and-pony shows.

The high level of creativity, expertise, and experience; the continuity; both the diversity and the commonality of the projects; and the presence of practice-focused researchers and foundation reps around the table provide a rare opportunity. The group recognizes that and has started looking for new ways to harness its potential. Ideas that have been floated include building a network that includes non-professionals, community awareness campaigns and state-level advocacy. Personally, I’m hoping the project stays focused on the how-tos of serving victims. In this era of “evidence-based practice,” the new buzzword for designing programs based on tried and tested techniques, that, in itself, would be a tremendous contribution.