San Francisco's Forensic Center: Building PG and APS Collaboration Talitha Guinn

1. San Francisco's Forensic Center: Building PG and APS Collaboration Talitha Guinn Elder Abuse Prevention at IOA Jill Nielsen, LCSW Adult Protective Services, City and County of San Francisco Mary Ann Warren, JD Office of the Public Guardian, City and County of San Francisco

2. Goals of Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Explore APS and PG frameworks for protecting vulnerable adults. • Facilitate communication between APS and PG to improve the quality of APS referrals for conservatorship and to facilitate the investigation process for conservators. • Learn how a multi-disciplinary forensic center model can improve client outcomes and enhance coordination and understanding between the PG and APS. • Learn to build collaboration between the PG and APS.

3. Why we are here To help those who help the vulnerable

4. How does the Forensic Center improve APS/PG collaboration? • Neuropsych evaluations as valuable tool • Cross-training about roles of partner agencies • Neutral communication forum • Early intervention – allows PG to provide feedback about information needed and possible alternatives • More appropriate and robust referrals from APS

5. Our Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . We are a true public/private partnership • Community-based • No medical center or medical model (LA and UCI) Our partners are representatives from the following agencies: • DAAS • APS • Public Guardian (PG) • SFPD • District Attorney • City Attorney • Ombudsman • IOA – Coordinates FC • IOA contracts to provide • Geriatrician • Psychologist

6. Beginning • Precursors to Forensic Center • Multidiciplinary Team Meeting (MDT) Started at IOA in 1981 • Multidisciplinary Assessment Team (MAT) starts with vision from IOA, Social Services, Law Enforcement and the DA’s Office • DA Harris proposed new elder abuse center in SF late 2006 • Planning with all partner agencies • Funding provided through Archstone Foundation and The City and County of San Francisco • Launched Jan 2008 – Five Year Anniversary 1/2013!

7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forensic Centers Four Forensic Centers in California San Francisco www.sfeafc.org Orange County www.elderabuseforensiccenter.com LA www.lacelderabuse.org San Diegohttp://www.sandiego.gov/sandiegofamilyjusticecenter/services Three similar models in US outside of CA Texas www.uth.tmc.edu/schools/med/imed/divisions/geriatrics/team-institute.html New York http://nyceac.com/ Hawaii http://www.elderjusticehonolulu.com/

8. Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Forensic Review meetings – Formal case consultation by our multi-disciplinary team of professionals • Coordinated Homevisits – Two or more participating FC team members go to the client’s home together i.e. Police and an APS social worker, Geriatrician and Geropsychologist • Medical evaluations – Geriatrician evaluates medical/mental status at the request of the team

9. Services Continued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Medical record review – Geriatrician reviews to determine medical status/standard of care inquiries • Psychological/Neuropsychological Assessments – Geropsychologist conducts per request of the team • SFPD – Office Hours at APS • Collaboration with community partners and city agencies on elder abuse public awareness campaigns, education to professionals, and protocol.

10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forensic Review Meetings Weekly 90 min. meetings at APS office 2-3 times a month Discuss ~2 new cases and 3 follow up cases on average Referrals of cases from any partner agency Most initially from APS Case Consultation Examine case from a multidisciplinary perspective Is this a crime? If so, what is needed for a successful prosecution? What are our goals? Safety – Harm Reduction – Prosecution – Referral to other agencies Discuss protocols, policy, and other “business”

11. Mission Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The San Francisco Elder Abuse Forensic Center will prevent and combat the abuse, neglect and exploitation of elders and dependent adults in San Francisco. This will be accomplished with the following strategies: • Improve communication and coordination among the legal, medical, social services professionals who investigate and intervene in cases of elder and dependent adult abuse. • Increase access to potential remedies and justice for those who have been victimized. • Educate policy makers, professionals, caregivers, older adults and their families about preventing, reporting, and stopping elder and dependent adult abuse.

12. Benefit to APS and PG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Consultation with Geriatrician – Benefit to PG and APS for case planning purposes • Targeted intervention for chronic self-neglect cases • Strategic planning with partner agencies to manage involuntary aspect of service planning • Relationship Building between all Partner Agencies

13. Data Jan 2008 - Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Our next data project is mapping abuse by zip code and type!

14. What Is Adult Protective Services? Adult Protective Services is a county-based program that intervenes to remedy or reduce danger to dependent adults and elders who are at risk of physical, sexual, mental or financial abuse, neglect or self-neglect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15. Adult Protective Services Mission To maintain the health and safety of dependent and elder adults in the community, in the least restrictive environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16. Adult Protective Services Goals Protect physical well-being of victims. Prevent or intervene to prevent financial abuse. Prevention education and services. Delay or prevent institutionalization. Maintain independent living. Link community services to reduce repeated referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17. Types of Abuse Physical Abuse Neglect Psychological Financial Abuse Abandonment Isolation Self Neglect/Inability to Manage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18. APS Interventions Conduct investigation and forward findings to local law enforcement as appropriate Arrange for the immediate safety of the individual Develop a plan for the care and safety of the individual and their property Initiate referral for conservatorship, when necessary Refer to community agencies and support resources General advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19. Guiding Principles Respect for self-determination of the client except when a crime has been committed A victim may refuse/withdraw consent at any time to an investigation or to services by APS, unless a Penal Code Section has been violated If an individual lacks capacity to give consent or is under the influence of other(s) a petition for temporary conservatorship may be initiated Least restrictive services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20. Public Guardian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mission of the Department of Aging and Adult Services To assist older adults and adults with disabilities and their families maximize self-sufficiency, safety, health and independence so that they can remain living in the community for as long as possible and maintain the highest quality of life.

21. Probate Conservatorship: What is it? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . To protect and care for the person and to administer the estate of those who, without assistance, cannot provide for the basic needs of food, shelter, or clothing or are unable to resist fraud or undue influence

22. Conservator of Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • There must be evidence that the proposed conservatee is unable to properly provide for his personal needs for physical health, food, clothing, or shelter • There must be evidence of a correlation between the deficit and the need for conservatorship

23. Conservator of the Estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . There must be evidence that the proposed conservatee is substantially unable to manage his financial resources or resist fraud or undue influence.

24. Temporary Conservatorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • There must be evidence of an urgent need - such as the need for a medical procedure or the need to safeguard assets in imminent danger of loss. • The probate conservatorship is not renewed automatically; it remains in place unless the conservatee or conservator petitions the Court for termination at any time

25. Obstacles for PG Conservators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Limited number of placement opportunities. • Greater number of clients requiring secure placements. • Increasingly complex financial abuse cases. • T-Cons can only be carried out when there is an urgent need. • Changes in requirements about notification to family members. Cases may be continued without proper notice.

26. LPS Mental Health Conservatorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Individual is determined to be gravely disabled secondary to mental illness and is unable/unwilling to accept treatment • Is going to be treated in a licensed locked psychiatric setting following stabilization of an acute episode

27. How to use LPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Process begins in acute psychiatric setting • Petition is filed by MD after 5250 (14 day hold) has been initiated • This provides for a 30 day period to investigate need for conservatorship and alternatives

28. Obstacles for LPS Conservators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Effort to use LPS as a means to provide treatment to chronic substance users • Limited availability of locked programs for mental heath clients who have organic and substance abuse problems concurrently

29. Public Guardian Option of last resort Court driven and highly regulated Involuntary service Adult Protective Services Crisis Oriented Realigned and loosely regulated Voluntary Service Differing Frameworks to Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30. Public Guardian Protect clients from exploitation and abuse Least restrictive options for care Promote client well-being Adult Protective Services Protect clients from exploitation and abuse Least restrictive options for care Right to self-determination Similar Frameworks to Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31. Collaborative Interventions through the Forensic Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Criminal remedies • Civil (Probate Conservatorship + referrals) • Enhancing safety • Medical • Psychological Services • Expert recommendations • Expert witness (med and psych) • Outreach

32. Case Vignette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Abused by daughter • “I wish she would die” • Left in bed without blankets, windows open in winter • Fell ill and hospitalized, but not for over 5 days • FC meeting • Emergency psych evaluation • Emergency conservatorship • Restraining order • Placed safely and anonymously

33. Interdisciplinary Education Learning about the limits of APS authority Role of the probate court for PG cases Medical, social work education for partners such as law enforcement Common understanding that conservatorship is not the quick-fix that we all wish it would be. Building Collaboration through the Forensic Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34. Building Collaboration through the Forensic Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Relationships are created and maintained. • Increased contact between APS/PG staff. • Common focus on helping vulnerable clients. • Enhanced understanding about challenges of each program.

35. Improved referral packets from APS APS workers have context for the information required. Requests for further information made in neutral setting and APS willing to cooperate. Tools and resources are brought forward during Forensic Center meetings to assist with referral process. Positive Outcomes from Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36. Avoiding Conservatorship Creative problem-solving happens during Forensic Center meetings. Conservatorship seen by all as measure of last resort. Geriatrician provides increased access to SF General Hospital to enhance safety Use of 2900 to protect assets Contacting regulatory boards for follow up on abusers Positive Outcomes from Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37. Efficiency More direct contact between agencies with less run around Medical consultations Psychological evaluations eases conservatorship process and better care plans. Added Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38. Advocacy Informed by Collaboration Recognized need for caregiver training End of life care education Developed a newsletter to raise awareness about scams Police education Bus Shelter Ads Added Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39. Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • On-going Education Needed -Rotation of Forensic Center partners -Refreshers needed for APS/PG staff • Demonstrating the Efficiency Aspect of the Forensic Center to all partners • Arriving at Consensus about Client Interventions

40. Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Lacking Necessary Tools - Depending on “Watchful Waiting” • Challenging Client Portraits • Building a Team -Engaging assigned representatives and maintaining their engagement.

41. Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mr. W. thought he won the lottery. All he had to do was send $40,000overseas so that the taxes and handling fees would be covered. He mentioned this to the bank teller as he exited the bank with a money order in hand. The bank teller called APS. APS knew who to call at SFPD, the PG, and the DA’s office. That same day, the police were able to intercept the payment at FedEX before it went out, and saved Mr. W’s life savings. The PG prepared and served a “2900” on the bank to marshal his assets. The PG then petitioned for conservatorship after obtaining a psychological evaluation through the Forensic Center.

42. ElderAbuse Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . There’s an App for that! Go to your app store and search ‘368’ App update. Over 2150 downloads! Boulder County Area Agency on Aging and William Mitchell College of Law in Minnesota Are creating an app based on our model. IOA exploring funding for app updates and developing an app for the general public.http://www.centeronelderabuse.org/368ElderAbuseCA.asp

43. Civil/Criminal Elder Financial Abuse Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder financial abuse can be both a civil wrong and a crime. Civil remedies primarily seek to help victims recover from the consequences of exploitation; criminal sanctions seek to punish and deter such wrongful conduct. both serve important public policy objectives and promote the legislature’s goal of reducing or eliminating elder financial abuse. While the same wrongful conduct can create both civil and criminal liability, the legal requirements and the practical considerations of each differ significantly. Generally, civil lawyers are unaware of the requirements for a successful criminal prosecution; similarly, prosecutors are often unaware of the requirements for a successful civil action. both may be frustrated that the other lacks greater interest or insight. The purpose of this publication is to bridge this gap by providing an overview of the law, issues, and practical concerns of elder financial abuse from both a civil and criminal perspective. its goal is to promote understanding between prosecutors and victim’s lawyers with the expectation that this will lead to greater cooperation and thereby help reduce elder financial abuse Hard copies available at the IOA table Download the PDF here:http://www.ioaging.org/File%20Library/Abuse/CivilCriminalResourceGuide_0512.pdf

44. The Journey Continues. We have grown as a team and we continue to re-evaluate our structure, and services, in an effort to improve outcomes for our clients.