Tuesday, October 24, 2006

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.

Wednesday, October 11, 2006

Perpetrators with Dementias

A couple years ago, a friend who runs a dementia care program asked me to talk to her staff following a tragedy involving a client, a man with Alzheimer’s disease, who'd killed his wife.

The staff was understandably upset. But what made matters worse was that some felt they’d seen it coming. They’d filed a report with APS, and a worker investigated. But since the violence was dementia-related and the client was already receiving dementia care services, the APS worker concluded there was nothing more he could do.

It was not my finest hour. The group wanted to know what they could or should have done differently; what would have happened if they’d gone directly to the police; what steps, if any, they could have taken to have guns removed from the client’s home (and those of other clients); and what the agency’s role should be when their clients are the ones abusing. I didn't have answers.

The case has haunted me. In retrospect, I doubt if these was anything they could have done differently, but it got me thinking about what we, as a profession, need to do. Clearly, we should be providing dementia care programs with guidance in what to do when they know clients have histories of domestic violence, how to assess future risk, and what to do to ensure caregivers’ safety. Not to mention working with law enforcement to ensure that violent elders with dementias are treated humanely.

The issue is particularly timely now as domestic violence theory and practice filters into elder abuse, and police are increasingly being instructed to use applicable domestic violence laws when responding to elder abuse cases. These developments are resulting in more elders with dementias getting entangled with law enforcement and ending up in prisons or institutions for the criminally insane. It's the prospect of these innappropriate responses, I believe, that has made some people in the dementia care field leery of the elder abuse, law enforcement, and adult protective services networks. Even when their clients are on the receiving end of violence, they may be subject to arrest as co-combatants.

There are no easy answers. Formerly peaceful, loving husbands who become violent with the onset of dementias shouldn't be forced to spend their final days in prisons. Yet, long-term batterers are also likely to become increasingly dangerous and unpredictable with the onset of dementia and shouldn't suddenly be absolved or excused. The fact that decline is usually gradual makes it even hairier to try to figure out the point at which people are no longer culpable for their actions.

These issues aren't going to be resolved by the dementia care community alone. Nor by the elder abuse/law enforcement/APS network. Coming up with fair and humane responses requires input from both sides. Nowhere does distrust and lack of communication between two fields threaten to have more heartwrenching results.