Department of Family and Protective Services

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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

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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.

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Overview of Presentation

Brief overview of APSCurrent trends in APSRecent changes in who APS servesUpcoming changes in how we

conduct casework Questions and Answers

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Mission

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

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APS Programs

APS Program has two primary components:

In-Home Investigations and Service Delivery

Facility Investigations

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Statutory AuthorityChapter 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.

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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 DeliveryIntake

Yes

Yes

YesNoNo

No

Current APS In-Home Process

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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

2009 2010 Est. 2011 Est. 2012 Est. 2013 Est. 2014 Est.

Population (Millions) 3.97 4.08 4.19 4.23 4.48 4.63

Age 18 to 64 with a Disabil ity 2.45 2.52 2.58 2.69 2.80 2.91

Age 65+ 1.52 1.56 1.61 1.54 1.68 1.71

0

1

2

3

4

5M

illio

ns

Texas Population Age 65 and over and Population Age 18 to 64 with a Disability

Age 65+ Age 18 to 64 with a Disability

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FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012Intakes 82,029 77,223 83,601 89,489 103,401 108,580 107,203

70,000

75,000

80,000

85,000

90,000

95,000

100,000

105,000

110,000

APS In-Home Intakes

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FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012Service Delivery Stages 35,350 35,547 36,691 38,095 42,940 43,611 46,101

30,000

35,000

40,000

45,000

50,000

APS In-Home Service Delivery Stages

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FY2006 FY2007 FY2008 FY2009 FY2010. FY2011 FY2012Total Duration 124.6 122.5 102.9 99.0 95.9 84.3 76.9Service Delivery Stage 57.8 51.8 48.9 48.0 45.0 41.4 37.7Investigation Stage 66.8 70.7 54.0 51.0 50.9 42.9 39.2

0

20

40

60

80

100

120

140

APS In-Home Durations

Investigation Stage Service Delivery Stage

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FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012

Ave. Daily Caseload 51.2 36.4 30 30.1 33.1 31 29.6

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30

40

50

60

APS In-Home Average Daily Caseloads

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FY2011 FY2012 FY2013 est. FY2014 est. FY2015 est.Caseload 31 29.6 31.2 32.2 33.2 Intakes 108,580 107,203 110,508 112,824 115,284

100,000

110,000

120,000

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30

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HHSC Forecast of APS In-Home Intakes and Caseloads FY2011 to FY2015

Caseload Intakes

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Key Casework Challenges Caseworkers are:

Decreasing (in FY 12-13 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

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Background on Changing Who We Serve

SB221 (82nd 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

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Types of Change Target who we serve as defined in rule and

policy:Two types of changes definitions of target

populations and definitions of ANEFor 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

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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

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Definition of Person with a Disability

A person with a mental, physical, or developmental disability that substantially impairs the person’s ability to provide adequately for the person’s care or protection.”

Proposed change is to define “substantial impairment” in rule: “grossly and chronically diminishes an adult’s 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?

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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 tweakedSWI GuidelinesPolicy

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What’s the Aging Network’s Experience and Feedback?

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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 DeliveryIntake

Yes

Yes

YesNoNo

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

?

InvestigationIntake

Yes

Yes

Yes

No

No

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

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: Children’s Research Center (CRC) Center for Girls and Young Women

40 State & Local and 10 international SDM Implementations

APS CredentialsCalifornia•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

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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

Strengths and Needs Assessment

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

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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

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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 willMake IT system changesTrain on the new policy and practice

In FY 2015, we implement

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Questions and Answers