1 Department of Family and Protective Services Increasing Efficiency and Effectiveness in Adult Protective Services: Implications for the Aging Network Kez Wold and Karl Urban June 17, 2013

2 Presentation Objective The Texas Adult Protective Services (APS) program is having to do more with less. We are taking a hard look at who we serve and how we serve them. This presentation describes one critical change already implemented and one being developed. To have a dialogue with the Aging Network about these changes.

3 Overview of Presentation Brief overview of APS Current trends in APS Recent changes in who APS serves Upcoming changes in how we conduct casework Questions and Answers

4 Mission The mission of Adult Protective Services (APS) is to protect the older adults and people with disabilities from abuse, neglect, and exploitation.

5 APS Programs APS Program has two primary components: In-Home Investigations and Service Delivery Facility Investigations

6 Statutory Authority Chapter 48 of the Texas Human Resources Code authorizes APS to investigate reports of abuse, neglect, and exploitation of: elderly persons (age 65 and older); adults with disabilities; and persons receiving mental health and/or IID services in a state supported living center, state hospital, community center, state center, licensed ICF/IDD), or via Home and Community-based Services (HCS) and Texas Home Living Medicaid waiver programs.

7 In-Home Investigations and Services In-Home investigations are conducted in private residences, room and board homes not subject to licensure, and/or adult foster care homes with three or fewer residents. APS may arrange for or provide the following services: emergency financial assistance for rent and utility restoration social services emergency shelter health services referral to or collaborate with other community services, including guardianship

Current In-Home Process Intake Received by SWI Meets Criteria ? Case Initiation Emergency Services Client Assessment: Risk + CARE ANE Valid? Closure Service Plan based on Outcome Matrix from CARE Tool ANE Remediated ? Investigation Service Delivery Intake Yes No Current APS In-Home Process

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10 Current APS In-Home Trends Target populations are increasing rapidly resulting, in the long-term, in rising intakes But durations are shrinking because… APS has implemented casework practice changes that have improved efficiency Mobile caseworkers As You Go documentation using tablet-PCs Management attention on pending cases and improved practice Resulting in, for now, falling caseloads

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18 Key Casework Challenges Caseworkers are: Decreasing (in FY biennium) Leaving (turnover is a problem) Lacking life experience/skills (new ones, especially) Practicing defensive casework practice – fear of the one bad case Managing a mobile workforce Uniform practice for all types of allegations and levels of client risk Limited ability to address needs of some clients (especially mentally ill, chronically poor) leading to less than optimal outcomes and frustrated (at best) or burned-out staff

19 Background on Changing Who We Serve SB221 (82 nd R) granted HHSC the authority to define In-Home ANE in APS investigations by rule in the Texas Administrative Code. Changes to definitions have allowed APS to: Focus on providing the most effective protection possible Make distinctions in the definitions between paid and unpaid caretakers

20 Types of Change Target who we serve as defined in rule and policy: Two types of changes definitions of target populations and definitions of ANE For APS to investigate, must be in target population and then must meet definition of ANE Screen more intakes out at Statewide Intake through better guideline Staff training and culture change

21 What Changed? Generally… Eliminate cases when the APS investigation will not alleviate the root cause Eliminate duplication of cases in which other entities have clearer responsibility and resources Streamline cases in which an expedited investigation would be more efficient

What Changed? Specifically…. Not investigate suicidal threat when there is no ANE Define Substantial impairment in TAC and clarify in policy (SSDI will no longer be an automatic qualifier) Must be emotional harm or physical injury to be abuse or neglect For unpaid caretakers, there must threat of harm for emotional/verbal abuse For paid caretaker, theft and may have caused Self neglect and caretaker neglect are separately defined Definition of sexual abuse based on consent; clearly define when consent cannot be given 22

23 Definition of Person with a Disability A person with a mental, physical, or developmental disability that substantially impairs the persons ability to provide adequately for the persons care or protection. Proposed change is to define substantial impairment in rule: grossly and chronically diminishes an adults physical or mental ability to live independently or provide self-care Current APS policy defines "substantially impairs" as "requires assistance" with one or more ADL or qualifies for SSDI/SSI – Put in place a better way of determining disability.

So What Happened? 24

The Drop in Intakes…. Scared us…. Caused us to go back and review intakes and rapidly closed cases to make sure we were not missing anyone So we tweaked SWI Guidelines Policy 26

Whats the Aging Networks Experience and Feedback? 27

28 Changing Casework Practice Currently APS treats all cases the same regardless of the allegation type or the potential risk to the client Moving forward, APS is: Implementing new tools to assess safety, risk of recidivism, and strengths and needs. Further targeting resources to address the most risky cases. Providing Caseworkers with tools to support decisions in the field. Each tool will help determine our response.

Current In-Home Process Intake Received by SWI Meets Criteria ? Case Initiation Emergency Services Client Assessment: Risk + CARE ANE Valid? Closure Service Plan based on Outcome Matrix from CARE Tool ANE Remediated ? Investigation Service Delivery Intake Yes No Current APS In-Home Process

Revised In-Home Process Intake Received by SWI Meets Criteria ? Safety Assessment Emergency Services Risk Assmt. Closure Service Plan based on Risk Assessment and Strengths and Needs Assessment ANE Remediated ? Investigation Intake Yes No Proposed Revised In-Home Process Valid Findings ? Strengths and Needs Assessment Low Risk Service Delivery Med/High Risk

Project Drivers Review of ANE definitions and the assessment processes revealed that new processes are needed to more effectively assess client safety and risk Practice relies on legacy tool – Client Assessment Risk Evaluation (CARE) and does not evaluate safety and risk Inefficiencies in policy divert APS resources from clients in most need ADM Project SB 221/New ANE Defintions Deficient Assessment Processes 'One Size Fits All' Practice Model Self-Neglect comprises 60% of Investigations Increasing Elderly Populations

National Council on Crime and Delinquency (NCCD) Mission: NCCD promotes just and equitable social systems for individual, families, and communities through research, public policy, and practice. Non-Profit; with focus areas in Adult Protective Services, Child Welfare, Adult Criminal Justice, Juvenile Justice Operates 2 Centers: Childrens Research Center (CRC) Center for Girls and Young Women 40 State & Local and 10 international SDM Implementations APS Credentials California Riverside County San Diego County Orange County Yolo County New Hampshire, National Institute of Justice Grant Minnesota County Collaborative National Adult Protective Services Resource Center partner Norfolk, VA

Safety Assessment Factors influencing vulnerability Current Danger Factors Interventions Safety Decision Components Is there current threat of serious harm to the alleged victim? What interventions are recommended to address threats to safety? Based on client and CG acceptance of interventions, what is the safety decision?

34 Risk Assessment and redefining Risk in APS What is actuarial research? A simple statistical procedure for estimating the probability that a critical event will occur at some future time. In the auto insurance industry, the critical event is a car accident involving a driver insured by the agency. Among breast cancer patients, the critical event is recurrence of cancer, and risk informs treatment determination. In this case, the critical event is the likelihood of future self- neglect or abuse/neglect by another person.

Risk Assessment Self-Neglect Index Maltreatment by Another Person Index Scored Risk Level Overrides Components What is the likelihood of future harm? Should ongoing intervention services be provided? What intensity of service is required?

Strengths and Needs Assessment Client domains Caregiver domains Prioritization Components What are the priority needs that should be addressed in service planning? What existing strengths can be used to address needs?

What are Implications for Casework Practice? Focus on recidivism and root cause. Safety vs. Risk, change in perspectives. Actuarial scored risk Informed decisions reinforcing intuition Real service planning Moving beyond bandaid approach 37

What are the Implications for the Aging Network? Closure of low risk client cases More intensive APS involvement with high risk client cases Community supports as strengths in service planning 38

39 Next Steps Business requirements are completed and tools are finalizing. System requirements for IT and policy for field is being developed In FY 2014, we will Make IT system changes Train on the new policy and practice In FY 2015, we implement

40 Questions and Answers