Adult Protective Services: Providing Context in an Aging State

The Adult Protective Services (APS) program is available through the Ohio Department of Job and Family Services (ODJFS) and administered by the local County Job and Family Services (CJFS). Counties are mandated to investigate reported abuse in one to three days, contingent on the severity of an allegation. If the county in which the reported abuse occurs determines there is abuse, they connect the older adult with support services to assist them and remediate the situation within three days, or within 24 hours following the report of an emergency.

Not only is there an increasing number of Ohioans aging in their homes, there is also an overall increase of older adults in the state

Elder abuse takes a variety of forms. Often, abuse, neglect, or exploitation is inflicted by someone close to the victim, such as a family member or caregiver. This makes it more difficult for an individual to come forward with a complaint. For every case of abuse that occurs, it is estimated that 23 remain veiled.[1] Individuals may hide their abuse for a myriad of reasons ranging from fear, shame, love or loyalty. Thus, it can often be difficult to understand the full scope of the problem in Ohio, and throughout the country.As Ohio moves to more of a home and community-based way of aging, a growing number of Ohioans, about one-in-10 individuals ages 60 and older, who choose to remain in their homes may experience abuse, neglect or exploitation [2]. The Elder Justice Roadmap is often used as a key resource for data when addressing the issues associated with elder abuse, and it provides many of the key data points used in this paper.[3]Created in 2014, the roadmap sheds light on a systemic concern that more data is continually needed to understand the evolving nature of APS with a growing aging population. Elder abuse not only takes place in the community, it also occurs in facility-based care settings. Ohio ranks sixth nationwide in supply of nursing home beds, with 93 thousand total beds. [4] Victims of elder abuse are four times more likely to be admitted to a nursing home and three times more likely to be admitted to a hospital.[5] Understaffing in nursing homes accounts for a 22 percent increase in hospitalizations nationwide.[6] Reports of abuse and neglect in nursing facilities are reviewed and investigated by the state Long Term Care Ombudsman program, reported to the Ohio Department of Health and, if criminal, to the Ohio Attorney General’s Health Care Fraud Unit. These reports remain separate from the ODJFS-run APS program. [7]Not only is there an increasing number of Ohioans aging in their homes, there is also an overall increase of older adults in the state. In 2010, 21.3 percent of Cuyahoga County was 60 or older, and in the projections for 2030, that number increases to 31 percent.[8] Ohio had more than 19.8 percent of its residents who were age 60 or older in 2010, and by 2030, that number will increase to more than 28.7 percent.[9] Nearly one fifth of Ohioans were 60 or older in 2010, and 11.7 percent of those seniors were at or below the poverty level.[10] This is a key measurement that sheds light on the susceptible nature of some of Ohio’s most vulnerable citizens.

Source: Ohio Department of Job and Family Services, APS Data Fact Sheet SFY 2013 - 2017

*Some reports have multiple primary allegations.

In state fiscal year (SFY) 2017, counties throughout the state received 16,241 reports of abuse, neglect, or exploitation of adults age 60 and older.[11] Roughly 70 percent of those reports were allegations of neglect, 14 percent involved an allegation of abuse and 18 percent were allegations of exploitation. [12] Although reports of abuse have thus far remained consistent, these numbers show the state’s need to further invest in the growing priorities of an aging population. APS are vital for Ohio to keep older adults healthy.

Source: Ohio Department of Job and Family Services, APS Data Fact Sheet for SFY 2017

*Some reports have multiple primary allegations.

Source: Ohio Department of Job and Family Services, APS Data Fact Sheet for SFY 2017

*Some reports have multiple primary allegations.

The Adult Protective Services line item (600534), within the ODJFS budget, is the only dedicated source of state funding for APS in Ohio. It funds a substantial portion of the APS program for many counties in the state, though additional allocations to APS and supportive services can be found in other state agencies and community levies. Each community funds differently the wraparound services that incorporate APS. Some communities have managed to maintain a somewhat robust APS system even as state resources dwindled, while other communities did not have the additional resources to assist with cuts to the program at the state level and maintained the required functions of the program. Counties may also utilize federal Title XX funds, available through the Social Security Act, for APS. A previous Community Solutions report outlines these funding mechanisms, and detailed below are the specific APS line-item funding allocations for the past 13 fiscal years.

Source: Legislative Service Commission

*This graph excludes one-time funds in FY 2015

** Funding as a separate line item for APS was temporarily ended in 2004 and didn’t resume until FY 2008/2009

In addition to the county and state JFS, local law enforcement, Area Agencies on Aging, local prosecutors, and probate courts all play crucial roles in the way APS are administered. The state has made significant progress in expanding the partnership between these groups and APS, through the creation of interdisciplinary teams (I-Teams); further doing so can greatly impact the outcome of reported abuse neglect, and exploitation for some of Ohio’s most vulnerable citizens.In addition to collaboration, data is a key component to understand the way these groups can work together to have the greatest impact on victims’ lives. A universal APS reporting information technology system is vital to understanding the ways professionals can continue to work together now, and in the future. In this issue of State Budgeting Matters, The Center for Community Solutions (CCS) seeks to examine the current and evolving state of the APS program in Ohio by providing an overview of the aforementioned programs, and a brief history of the state APS program.

House Bill 483

In 2014, the 130^thGeneral Assembly made strides in advancing the state’s APS program through the passage of House Bill 483. In addition to a one time appropriation of $10 million, House Bill 483 created an Adult Protective Services Funding Workgroup housed within ODJFS. The workgroup was chaired by Greg Moody, director of the Office of Health Transformation, and comprised of 20 members from across the aging and health and human services spectrum, to represent both county and state interests.The workgroup was charged with investigating funding gaps in the APS program, identifying best practices from throughout the state, developing ways the APS program could work alongside other programs at various state health and human service agencies and coordinating with a similarly created workgroup at JFS, the Children’s Services Funding Workgroup, to see where existing models could be further developed.The workgroup’s suggestions focused on the most efficient way to utilize the $10 million appropriated in House Bill 483, by specifically directing funds to fill the practical and financial gaps that existed in the APS system at the time. In addition, a portion of this one-time appropriation was used to train ODJFS staff on current APS law and best practices.An additional provision that came from the workgroup was the recommendation that all counties have I-Teams. The workgroup realized that the APS system was fragmented between agencies and community service providers, often making it difficult for individuals to access the services that they needed. I-Teams at the community level, and throughout the state, were created to better align services to assist individuals in need; they are composed of agencies and service providers across the older adult and criminal justice spectrum. These organizations coming together have proven to better assess and align care for older Ohioans who find themselves receiving APS through programs and services that are already available in the community, or are more easily utilized through collaboration. Though initially challenging for some larger communities, the I-Teams have evolved to fit the needs of the communities where they exist.As a part of their charge through House Bill 483, the workgroup recommended six priorities to spend the $10 million one-time appropriation:

Define core minimum APS program requirements statewide
Implement a statewide APS data collection and reporting system
Implement a state APS hotline
Provide one-time all-system training aligned to meet core requirements
Provide one-time APS Planning Funds for counties to meet core requirements
Provide a one-time APS innovation Fund to encourage multidisciplinary collaboration and build system capacity to meet core minimum requirements

House Bill 64

In the 2016-2017 state budget (131^st General Assembly)--House Bill 64 ODJFS was required to create and maintain a statewide APS information system. This information system is in the early stages of implementation, with the eventual goal of creating more unity and awareness in counties across the state that are assisting individuals on a case‐by‐case basis. To assist with these early and numerous changes to the APS system, the Ohio APS Advisory Council was created to provide guidance and recommendations as changes are implemented. (The Center for Community Solutions is a member of the council.) Organized and operated under ODJFS, the Council is used as a platform for interested parties around the state to come together to advance better APS practices. Since September, 2016, the council meets to carry out these goals and the reforms that the state continues to implement with counties and communities around the state.House Bill 64 implemented several changes recommended by the APS Funding Workgroup that was established in the Mid-Biennium Review (HB 483, 130^th General Assembly), discussed above. One significant change was the development of a statewide data system for APS. This data system includes records of all reported cases of abuse, neglect and exploitation across the state. After months of planning, the statewide data system for APS went live on October 1, 2017. ODJFS provided trainings on the new system to counties, and provided regular updates on its development to stakeholders through the APS Advisory Council. The data in this system will eventually be used to report information to the federal level with more detail than was possible with a de-centralized data system.There are two key improvements in the new system. First, having an automated system for case records eliminates the possibility of missing information contained in paper files. Previously, with paper files, information could be missed due to a caseworker’s time off or transition to another position. Having a fully automated, centralized data system ensures that case information is available to everyone who needs to access it. Secondly, the system is now statewide, which means that comprehensive data, including case history, is available regardless of the county. Having the system in place will offer a clearer and fuller picture of adult protective services, and the clients served across the state, eventually yielding data that can better inform policy decisions.In addition to the creation of the council and IT changes, House Bill 64 requires ODJFS to provide training on the implementation of the APS statutes, and requires all protective services caseworkers and their managers to complete the training on procedures to be followed when local officials are handling allegations of abuse. The training has been fully developed and implemented, with additional changes coming based on the most recent state budget. Of particular note in House Bill 64 was the appropriation of $2.6 million in both FY 2016 and FY 2017 for APS.[13] This nearly 72 percent increase in the funding from the previous fiscal year was appropriated for additional administrative costs for each county’s APS program through the APS line item. The increase in funds sets this biennial budget allocation apart from previous years. It has had significant impact on counties who have long sought to allocate more resources for one staff person to oversee the APS program in their county. Many counties currently have APS workers split their time between APS and other programs. Though this increase is not enough for a full salary, it was a significant investment for many counties.

There are two key improvements in the new system. First, having an automated system for case records eliminates the possibility of missing information contained in paper files. Second, the system is now statewide.

House Bill 49

House Bill 49 was the most recent state operating budget enacted by the legislature and signed into law by Governor Kasich in mid-2017. The enacted version of the budget increased APS funding by $100,000 in each fiscal year. This change provides much needed services to counties as they work to ensure the safety and security of Ohio’s aging population. The additional funds show a continued investment by the General Assembly in APS as it moves forward with advancing the programs around the state.Over the past three General Assemblies, multiple stand-alone pieces of legislation were introduced to further advance the state’s progress with APS. Each was unsuccessful as it made its way from the House to the Senate. This is similar to what happened with APS provisions in the state budget, as the Senate removed the House’s provisions. The language from several of the stand-alone pieces of legislation made up what eventually was enacted in the budget.Included in the enacted version of the budget were provisions that codified the Attorney General’s Elder Abuse Commission, allowing the commission to continue through possible administration changes. Previously, proposals were made around changing various definitions of exploitation and neglect. Defining these two words in particular has been difficult for the state, and often was one of the main reasons it was difficult to pass stand-alone legislation. Requirements were added for ODJFS to create, and make available, educational materials for individuals within JFS and mandated reporters. [14] The available materials will assist mandatory reporters that were added in the budget, such as medical professionals (e.g., surgeons) and individuals in the financial sector, which has long been a goal of advocates. In total, the key provisions of the bill include:

Notifies an adult’s closest relative of a report in the event of a court order
Codifies the Elder Abuse Commission
Permits county prosecutors to petition the courts for orders involving APS
Requires APS to notify law enforcement if they feel an individual may be criminally exploited
Modifies information being released to the state APS IT system

These additional revisions to the current law, though complex, continue the work in the budget to make more comprehensive changes and revisions to APS in Ohio.

One of the most impactful ways to affect results in APS is through awareness.

Excluded in the as-passed version of the budget are two provisions vetoed by the governor. One would have required the county APS programs to reimburse local law enforcement and county prosecutors for investigating and prosecuting APS cases. In his veto message the governor stated, “Law enforcement entities and county prosecutors are not under the purview of ODJFS and therefore the ability of ODJFS to effectively hold them accountable for the rules required under this section is uncertain.”[15] The additional veto language removed a requirement in regard to state memorandum of understandings (MOU). Though MOUs are often burdensome for large counties, such as Cuyahoga, those issues could be resolved in a less drastic manner.

Conclusion

One of the most impactful ways to affect results in APS is through awareness. Awareness in communities across our state, and in state agencies to better serve these individuals. One of the goals of this State Budgeting Matters is to explain the recent changes the state legislature has made to the APS program here in Ohio, and to paint a complete picture of where the state has come from and where it continues to move.Research shows that successfully preventing elder abuse can save victims and families from undue trauma, while also saving state resources that could be quickly exhausted by such cases. Staffing a full-time APS case worker in each county is imperative to secure the safety and wellbeing of Ohio’s older adults. A standardized data system, which is currently underway in the state, will allow for data to be accessible throughout the state now and in years to come, which will provide a more complete understanding of the needs of Ohio’s aging population.[1] Connolly, Marie-Therese, JD, Bonnie Brandl, MSW, Risa Breckman, LCSW, 2014. The Elder Justice Roadmap. Accessed November 2017. A stakeholder Initiative to respond to an Emerging Health, Justice, Financial and Social Crisis. https://www.justice.gov/file/852856/download [2] Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University, & New York City Department for the Aging. (2011). Under the Radar: New York State Elder Abuse Prevalence Study. Self reported prevalence and documented case surveys [Final Report]. Retrieved March 24, 2014, from http://www.lifespan-roch.org/documents/UndertheRadar051211.pdf; Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. J. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292-297. The New York State prevalence study found rates of about 7.6% (p. 32), whereas the Acierno study found rates between 11 and 14%. (p. 294). Thus, this report uses “about one in ten.”[3] Connolly, Marie-Therese, JD, Bonnie Brandl, MSW, Risa Breckman, LCSW, 2014. The Elder Justice Roadmap. Accessed November 2017. A stakeholder Initiative to respond to an Emerging Health, Justice, Financial and Social Crisis. https://www.justice.gov/file/852856/download [4] Bowblis, J. and Applebaum, R. Using National Data to Examine the Quality of Care in Ohio’s Skilled Nursing Facilities. Scripps Gerontology Center. Accessed December 2017.[5]Connolly, Marie-Therese, JD, Bonnie Brandl, MSW, Risa Breckman, LCSW, 2014. The Elder Justice Roadmap. Accessed November 2017. A stakeholder Initiative to respond to an Emerging Health, Justice, Financial and Social Crisis. https://www.justice.gov/file/852856/download[6] Connolly, Marie-Therese, JD, Bonnie Brandl, MSW, Risa Breckman, LCSW, 2014. The Elder Justice Roadmap. Accessed November 2017. A stakeholder Initiative to respond to an Emerging Health, Justice, Financial and Social Crisis. https://www.justice.gov/file/852856/download [7] Adult Protective Services Data Fact Sheet for SFY 2017. Accessed December 2017.[8] Scripps Gerontology Center. Miami University. 2015. Ohio’s 60+ Population by County 2010-2030. Accessed December 2017. https://www.ohio-population.org/wp-content/uploads/2015/08/New-Poster.pdf [9] N. P Ritchey, S. Mehdizadeh & T. Yamashita. 2012. Projections of Ohio's Population 2010-2030. Scripps Gerontology Center, Miami University, Oxford, OH. Accessed December 2017. https://www.ohio-population.org/wp-content/uploads/2015/07/Proportions_age_groups_proj_data_JUN26_2012.pdf [10] Scripps Gerontology Center. 2013. Projections and Characteristics of the 60+ Population. Scripps Gerontology Center. Miaimi University. Accessed December 2017. https://www.ohio-population.org/wp-content/uploads/2015/07/Ohio-60-.pdf[11] Adult Protective Services Data Fact Sheet for SFY 2017. Accessed December 2017.[12] Imbd.[13] Legislative Service Commission. “LSC Greenbook.” Department of Job and Family Services. September, 2015.Accessed September, 2017. https://www.lsc.ohio.gov/documents/budget/131/MainOperating/greenbook/JFS.PDF [14] A mandated reporter is an individual or professional group of individuals who is required by law to immediately report instances of abuse or neglect.[15] United States. State of Ohio. Office of Governor John Kasich. By John R. Kasich. June 30, 2017. Accessed July 28, https://assets.documentcloud.org/documents/3883457/Kasich-2017-Veto-Message.pdf.