APS and the Aging Services Network: Congruencies and Conflicts

1. APS and the Aging Services Network: Congruencies and Conflicts William F. Benson National Policy Advisor, NAPSA Principal, Health Benefits ABCs

2. A few words about NAPSA • Represents interests of states’ APS programs • Membership includes: former & current APS administrators and staff, state & local APS agencies • Mission to improve quality & availability of protective services for disabled adults & elders who are abused, neglected or exploited

3. A few more words about NAPSA • Partner in National Center on Elder Abuse (NCEA) funded by AoA (3 partner orgs) • National training events – Annual Conference • Research & innovation • Newsletter • Founding member of Elder Justice Coalition • www.apsnetwork.org

4. The Aging Network • Purpose: • Work with and on behalf of persons age 60+ to allow them to have the highest quality of life and to remain independent to the maximum degree possible. • Origin: • Created by the federal Older Americans Act in 1973

5. Adult Protective Services • Purpose: • To investigate reports of abuse, neglect, self- neglect and exploitation of adults with disabilities age 18+ (42 states at minimum) • To intervene to protect the victim to extent possible • Origins: • Title xx (SSBG) spurred development (1970’s) • Created by state laws and funded by state $’s

6. Aging and APS Services • Aging focuses on: • Direct services to improve senior’s well being • Systemic advocacy for benefits and services • Advocacy under elder rights programs • APS focuses on: • An objective investigation • Victim safety & protection

7. Aging Administrative Structure • A State Unit on Aging (SUA) and • Area Agencies on Aging (AAA) • Both mandated by the federal OAA • Direct services to seniors • Most often provided by not for profit agencies under contract or grant • Myriad services provided to help persons remain at home with a high quality of life

8. APS Administrative Structure • APS • Majority created within state umbrella human services departments • Half now in SUA’s (trend is to move to Aging) • States administer APS either: • Directly by state employees • Through county agencies • A very few states use contracted agencies • In 2002 5 states had APS located in AAAs

9. Funding Sources Aging Network • Federal OAA funds • State funds • Medicaid (in some states) • AAAs and local providers: • May receive local public funds • Fund raise for donations and grants • Never enough money to meet all the need! • Current economy → reduced $ & services

10. Funding Sources - APS • State Funds (vast majority) • Perhaps some county funds in those states which work through counties • SSBG • 34 states use • Amounts to about 6% of total SSBG funds • Has been significantly reduced from earlier funding levels • APS is severely underfunded in most states • Current economy → APS budgets slashed

11. Funding Sources - APS • Current economy → APS budgets slashed • Of states reporting, last year: • 41% had budgets cut • 26% reduced services • And this year: • 46% are experiencing budget cuts • 33% indicated reductions in staff • 25% are reducing services NASUA Survey

12. Role Considerations - Aging • Eligibility based on: • age • interest in services • need for services (for in home help, e.g.) • Low-income (for Medicaid waiver services, e.g.) • Services are provided on a voluntary basis • Services are provided in the community and in private homes

13. Role Considerations - APS • Eligibility based on: • Age • In most states, must be an adult 18 and older • Some states have two APS Programs:18–59 + 60+ • Some states serve adults with disabilities 18+ but all persons 65+ • Disability (must be unable to care for and protect self – note: state laws vary) • Allegation and then substantiation of abuse, neglect, self neglect or exploitation

14. Role Considerations - APS Victim with capacity may refuse services Victim lacking capacity may be served involuntarily (state laws differ) Determining capacity is a major and very difficult part of APS work Many APS cases involve criminal behavior and so involve law enforcement, etc. APS cannot refuse to respond to an eligible case and cannot create waiting lists

15. Roles Considerations - APS • Services are provided: • in the home • in facilities for DD and MI (differs by state) • In long term care facilities (in about 50% of states APS investigates in LTC facilities) • Confidentiality is paramount for safety • In most states many professionals are mandated by law to report abuse to APS

16. Principle Partners - Aging • Senior organizations and advocates • Health care providers • Home health • Hospitals • Long term care facilities • Medicare and Medicaid agencies • Public and private senior housing

17. Principle Partners - APS Law enforcement & prosecutors Probate and civil legal courts Code enforcement; fire departments; EMTs Public health agencies Health services (in home, hospitals, private Drs.) Disability services and facilities Long term care facilities Financial institutions Public and senior housing Domestic violence and sexual assault programs

18. Links between APS and the Aging Network Often serve the same clients 2/3’s of APS cases involve persons 60+ Aging services are often a lifeline for APS clients, allowing them to live more safely in the community Aging services reduce victim isolation, an extremely important factor in prevention

19. Links between APS and the Aging Network Close coordination between the Aging Network and APS on individual cases can mean much more effective and protective services for clients AAA’s often provide critical leadership and resources to Elder Abuse Coalitions, raising awareness of the issue and of APS

20. Aging Elder Rights Programs – An Important Link to APS • OAA authorized and funded (at low levels) • Call for advocacy for vulnerable seniors • Long Term Care Ombudsman Program advocates for LTC residents on individual and systemic basis; OAA calls for independence • Elder Abuse Prevention – Elder abuse awareness and training (<10¢ per US senior) • Legal Services – legal assistance for seniors

21. Aging Elder Rights Programs Traditionally not viewed as “core” aging services similar to nutrition programs, etc. Clients of ER Programs thus are often not viewed as “core” aging constituency Network advocacy for funding increases has traditionally focused on “core” services and clients

22. Areas of Potential Conflict between Aging Network & APS Confidentiality restrictions on APS often raise barriers between agencies Aging Network may not be able to provide services APS deems crucial Aging Network may not feel it is safe to send workers into APS client homes, or may terminate services to a client who does not cooperate with the care plan

23. Areas of Potential Conflict APS must be able to operate with arms length independence in order to objectively investigate & be credible APS has very different administrative needs; e.g. data systems for aging services usually do not meet APS’ needs APS cannot be regarded as just another aging service

24. Areas of Potential Conflict between Aging Network & APS • APS must sometimes investigate Aging Network employees and contractors for alleged abuse, neglect or exploitation • Examples have included: • In home service providers • Nutrition providers • Van drivers • AAA staff & board members

25. Areas of Potential Conflict between Aging Network & APS • Question: • If your AAA (or the SUA in your state) administratively controls APS, have careful firewalls be erected to insure that APS can carry out an objective investigation with no interference and no fear about where it will lead? • If not, can you see the conflict of interest involved?

26. Areas of Potential Conflict between Aging Network & APS • Question: • If, as is generally the case, no clear firewalls have been erected, do you think it’s possible that the lack of APS independence: • Could harm clients? • Could mean abusers are never held accountable and could go on to harm others in the future? • Might lead to really bad publicity for the agencies involved if a compromised case ever goes public?

27. Culture Clash • Aging Network has many difficult clients, but does not generally deal with: • Violence and illegal drugs • Many other different crimes • Total environmental filth • Providing services involuntarily • Being unable to refuse a case if client eligible • Appearing in court; preserving evidence

28. Cultural Clash APS faces all the above every day APS is “messy” and clients are often unpleasant and uncooperative APS workers often face danger on the job and can be threatened with violence and often are threatened with lawsuits APS must navigate among many diverse partners

29. Elder Justice Act – Tricky Riding Ahead?

30. EJA Background Lengthy Congressional History • “Protective Services for the Elderly” – Senate Special Committee on Aging, July 1977 • “Protective services probably have a more profound effect upon older Americans than any other age group…This need is likely to intensify in the years ahead as our population becomes older”

31. EJA Background Lengthy Congressional History • 1985 -- "Elder Abuse: A National Disgrace" • Echoed 1981 study; called for Federal assistance to states to combat elder abuse using 1974 federal child abuse law as model • States spent $22.14 per child resident for CPS versus $2.91 per older person for elderly protective servicesSen • Senator Breaux & Special Committee on Aging – hearings 2001-2003; EJA 2003

32. Source: Congressional Research Service

33. Elder Justice Act – 111th Congress • S. 795 (Hatch, Lincoln, Kohl, Snowe) – introduced 4/2/09 • Amends the Social Security Act by adding Elder Justice to an amended Title XX, entitled Block Grants to States for Social Services and Elder Justice and adding a new Subtitle 2 - Elder Justice • H.R. 2006 (King, Schakowsky, Baldwin)

34. What the EJA means for Adult Protective Services (APS) • First dedicated federal funding for APS • $100 million in new money to states for APS • $25 million in new money for APS demo grants • $4 million for HHS for a federal “home” for APS

35. What the EJA means for APS: State Funding Adult Protective Service Grant Program (State Formula Grants) -- Use of Funds • Authorizes $100 million • Funds may be used only by states and local governments to provide adult protective services & may only be used for APS. • State receiving funds would be required to provide these funds to the agency or unit of state government having legal responsibility for providing adult protective services in the state. • Each state would be required to use these funds to supplement and not supplant other federal, state, and local public funds expended to provide adult protective services.

36. What the EJA means for APS: National Demonstration Grants State Adult Protective Service Grants (Demonstration Program) – Authorizes $25 million “Would require the Secretary to establish grants to states for adult protective service demonstration programs. Funds may be used by state and local units of government to conduct demonstration programs that test: training modules developed for the purpose of detecting or preventing elder abuse; methods to detect or prevent financial exploitation and elder abuse; whether training on elder abuse forensics enhances the detection of abuse by employees of state or local government; and other related matters. States would be required to submit applications to the Secretary.”

37. What the EJA means for Adult Protective Services (APS): A Federal “Home” Focal Point for APS Within HHS • Would establish functions with respect to Adult Protective Services (APS) to be administered by the Secretary to provide leadership to the states’ programs. • Functions include providing funding and support to state and local adult protective services offices that investigate reports of abuse, neglect and exploitation of elders and vulnerable adults; collecting and disseminating information on abuse in coordination with the Department of Justice; developing and disseminating information on best practices; conducting research and providing technical assistance to states that provide or fund protective services. • Authorizes $4 million

38. EJA - S. 795 & H.R. 2006 • Collection of Uniform National Data on Elder Abuse, Neglect and Exploitation • Grants & Incentives for LTC staffing • Establishes an Elder Justice Coordinating Council in the Office of the Secretary of HHS.

39. EJA - S. 795 & H.R. 2006 – LTC Ombudsman Grants & Training • Improve capacity of LTCOPs to respond to/resolve complaints about abuse & neglect • Pilot programs with state & local ombudsman entities • Authorizes $5 million-$10 million over time • Ombudsman Training Programs re elder abuse, neglect & exploitation – authorized at $10 million

40. EJA in the House – H.R. 2006 • DoJ Provisions: • Provide resources to states for improved prosecution. • Require prompt reporting of crimes in nursing homes. • Make the Department of Justice responsible for a coordinated federal response to elder justice. • DOJ would provide grants to support state prosecutors, including employees of State Attorneys General and Medicaid Fraud Control Units handling elder justice-related matters.

41. Social Services Block Grant (SSBG)

42. Social Services Block Grant (SSBG) • SSBG (Title XX, SSA) is a capped entitlement used by states, counties, and non-profit organizations to provide critical services that help people to remain in their homes or community. • For the elderly it funds such services as Adult Protective Services, Home-Based Services, Adult Day Care, Adult Foster Care, and Home-Delivered and Congregate Meals.

43. Social Services Block Grant (SSBG) • During welfare reform, Congress and the Governors agreed to reduce SSBG funding to $2.38 billion for 5 years and then return it to its former level of $2.8 billion in 2003. • Funding was reduced again in 1998 and is currently $1.7 billion a year. • Bush’s budget for ‘07-’09 called for further reduction of $500 million • Rejected by Congress -- $1.7 billion for FY ’09 • Expect to be level funded in FY 2010

44. APS and the Aging Network Thank you! For more information contact NAPSA at: www.apsnetwork.org