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What is success? an exploration of person-centered intervention of complex elder mistreatment

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What is Success?
An Exploration of Person-Centered Intervention of
Complex Elder Mistreatment

by
Julia Margaret Rowan

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(GERONTOLOGY)
December 2019

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ACKNOWLEDGMENTS

"Alone, we can do so little; together we can do so much."
-- Helen Keller
This dissertation is dedicated to those who nurtured my curiosity through conversation and
sharing literature, who created spaces for me to read, think, and write, and were consistent sources of
comfort and encouragement. Several directly influenced the work in this dissertation. Zach Gassoumis, a
trusted friend and colleague, was instrumental in connecting me with people for collaboration. I relied on
Zach for informal “reality-checks” on my research and emotional state. Zach gave me a forum to vent,
sessions which would end in laughter, and brainstorms that seeded future projects. His brilliant questions
provided direction, especially in thinking about multidisciplinary teams. Susan Enguidanos, an expert in
qualitative research, delivered instrumental direction on the research methods. She helped make sense of
data that was dizzyingly rich, and recommended structure and guidelines for analysis. Equally important,
Susan gave me laughter, silence, and retreat when I needed it most, and will always be a dear friend.
The Forensic Center leadership team, Diana Homeier, Allyson Young, and Kathleen Tor
orchestrated an essential conduit for me to connect with frontline workers helping victims of abuse.
Observing case discussions of the Forensic Center MDT brought me closer to the vexing realities of
helping abuse victims. This dissertation focuses on the courageous work of the Forensic Center Service
Advocate, Cherie Fowler. Her keen intuition, observations, and memory drove the collection of
information that was crucially important for this research. Her painstaking thinking and typing unearthed
more information than any of us anticipated.
The Secure Old Age Lab, especially Jeanine, Kylie, Laura, Haley, Liz, Gerson, and Kelly, gently
challenged me to be a better thinker. I cherish memories of conversations in our shared office, validating
one another’s experiences as we learned to conduct research, celebrating victories, and dreaming of a
better world. A special thanks to Gerson, for his partnership in Chapter IV and late-night emails verifying
coding and running last-minute analyses. Kelly’s enthusiasm for story and research, and tireless hours of
Rowan Dissertation – Fall 2019 3

coding inspired and energized me in the final stretch of analysis and writing for Chapter III. With her
help, “work” became almost effortless.
Through this entire process, my family’s love and pride nourished me. I thank my beloved
husband and best friend, Joe, who supported me with steady love and encouragement. We often joked that
as I progressed through my studies, he gained the equivalent of a PhD providing therapeutic support.
However, his emotional sensitivity and timely words of wisdom stem from innate qualities; I’m not sure
they can be taught. I am so fortunate and grateful for his patience, flexibility, and for inspiring me to be
positive, work hard, and play harder. A special thanks to my cousin Carly, who read this entire
dissertation for edits; to my cousin Leah, who gave me an open invitation to stay at her home to be closer
to campus and offered kindness and solace; Aunt Mela, who texted me encouragement around the clock
and bragged about me to her colleagues and friends; to my Mom, Rosa, who was always available by
phone when I needed uplifting; to my brother Steve and sister Rosie, for understanding when I had to
miss family gatherings to write.
Most importantly, this dissertation would not exist without the guidance of my mentor Kate
Wilber, a visionary and a trailblazer, who made it possible for me to pursue topics I am passionate about.
Kate showed me how to trust myself by trusting me as I muddled through data that was messy and
chaotic. She encouraged my ideas, even those I struggled to articulate, and showed her excitement with
the smile in her eyes. Kate taught me a lesson that will forever influence my mindset: success is often
built upon failure, and sometimes success isn’t what or where we anticipated it would be.

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TABLE OF CONTENTS

ACKNOWLEDGMENTS 2
LIST OF TABLES 6
LIST OF FIGURES 7
ABSTRACT 8
CHAPTER I: Introduction 11
Elder Mistreatment Interventions: Defining Success 11
What do Victims Want? 12
Why Person-Centered Care? 13
Complexity of Elder Mistreatment 14
Multidisciplinary Teams: A Leading Intervention 15
The Present Research 15
CHAPTER II: “It’s Complicated”: Person-Centered Care of Elder Mistreatment 18
Introduction 18
Background: Autonomy and Protection in Elder Mistreatment 19
Design & Methods 21
Setting 21
The FCSA Intervention 22
Sampling and Data Collection 22
Results 23
Case 1: Ms. M 23
Case 2: Ms. R 26
Discussion 28
Conclusion 32

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CHAPTER III: “Wicked Problems”: An Exploration of Issues Concurrent to Elder Mistreatment 34
Introduction 34
Methods 35
Results 37
Participant Characteristics 37
Issues Concurrent to Elder Mistreatment 38
Discussion 49
Conclusion 51
CHAPTER IV: Toward Nationwide Replication of Elder Mistreatment Multidisciplinary Teams 52
Introduction 52
Methods 53
Project Components 53
Data 54
Analytic Strategy 55
Results 55
Barriers and Facilitators of Making Teams Work 57
Measuring Success 63
Discussion 69
CHAPTER V: Conclusion 73
What is success? 74
Recommendations for Person-Centered Care for Victims of Elder Mistreatment 74
Complexity: The whole is greater than the sum of the parts 77
Future Research: Complexity-Informed Evaluation 77
REFERENCES 80

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LIST OF TABLES
Table 3.1 Sample Characteristics 38
Table 3.2 Issues Concurrent to Abuse and Neglect 39
Table 4.1 Barriers and Facilitators Sub-Themes 60
Table 4.2 Measuring Success of MDTs 65
Table 4.3 Process and Evaluative Questions 68

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LIST OF FIGURES

Figure 4.1 Lewin’s Force Field Analysis Model 53
Figure 4.2 Analytic Process 55
Figure 4.3 MDT Force Field Analysis 63

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ABSTRACT
Elder mistreatment (EM) effects approximately 5 million older adults in the US each year
(Acierno et al., 2010), with enormous costs to victims (Pillemer, Burnes, Riffin, & Lachs, 2016), society
(Dong, 2015; Metlife, 2011), and their loved ones (Breckman, Burnes, Ross, Marshall, Suitor, Lachs, &
Pillemer, 2017). Despite improved knowledge on the nature and scope of the damage caused by EM, little
is known about how to help victims. Intervention research is scarce; of the systematic reviews of EM
interventions published in the past 10 years, not one demonstrated improvement in safety from abuse
(Fearing, Sheppard, McDonald, Beaulieu, & Hitzig, 2017; Ploeg, Fear, Hutchinson, MacMillian, &
Bolran, 2009; Baker, Francis, Hairi, Othman, & Choo, 2016), partially due to difficultly collecting data
on repeat EM. Most is not reported (Jackson, 2017), so short-term reduction of EM risk factors are the
most common intermediary indicators of intervention success. However, heterogeneity of case
characteristics and variance in individualized victim perception of appropriate action may result inability
to detect what may be meaningful change for EM victims using standardized measures of risk.
An untapped source of information on defining success in EM intervention are the victims. No
studies have solicited victims for definition of success, which services they prefer, or guidance in
designing EM interventions. Many EM victims refuse help, and reasons are not well studied. Policies in
Adult Protective Services (APS), the frontline responder to reports of suspected EM, favor autonomy of
those served by prioritizing victim right to refuse assistance (NAPSA, 2013). Rates of refusal of APS
services ranges from 13 to 58%, and most who choose to accept services do not pursue recommendations
(Burnes, Rizzo, Gorroochurn, Pollack & Lachs, 2016). Scant research on victim perception of their abuse
suggests that fear of nursing home placement and unwanted punishment of their abusers may be driving
declination for help (Lachs, 2002; Hightower, Smith, & Hightower, 2006; Baulaurier, Seff, Neewman &
Dunlop, 2007).
In absence of evidence-based guidance on intervention approach, there is robust literature
demonstrating the positive impact of facilitating choice in older adults (Mallers, Claver, & Lares, 2014).
Person-centered Care (PCC) is an approach to incorporating preferences into care and has a strong
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evidence-base for improved physical and cognitive outcomes in medical and long-term care settings
(Kogan, Wilber, & Mosqueda, 2015). PCC is recommended for EM victims (Jackson, 2017; Burnes,
2017) and has been adopted into APS ethical principles (ACL, 2016). Yet, there is no consensus on
approaches for applying PCC framework from health care settings to EM interventions. Research is
needed to determine program structure and resources required to provide PCC to EM victims, and to
identify policies that may impede PCC care delivery. To fill this gap, this dissertation applies formative
evaluation to establish a foundation for understanding process, and outcomes of PCC for EM victims.
Lack of victim perspectives remains a significant blind spot and is a top-rated priority by elder
justice researchers, practitioners, and policy-makers (Connolly, Brandl, & Breckman 2014; Jackson,
2017; Jackson, 2016; Stahl, 2015), so Chapter II of this dissertation begins with exploration of victim
preferences in relation to practitioner goals using case study analysis of a person-centered case
management program, a Forensic Center Service Advocate (FCSA). This study will identify process
elements facilitative and prohibitive to incorporating victim preferences into case plan. Chapter III is an
examination of EM complexity. Though EM is known for being intractable for various reasons, and more
intensive and individualized interventions are needed to assist the most complex casework (Navarro,
Wilber, Yonashiro, & Homeier, 2010), there is no objective measure for level of complexity. Without
delineation of elements and nature of EM casework that are inherently difficult to resolve, ability to
design effective interventions is limited. Research on complexity will inform service provision with
context surrounding need of more intensive assistance, feasible selection of outcomes and service
timeframes, and will enhance intervention evaluation with ability to control for level of difficulty. Chapter
III lays the groundwork for quantifying complexity with a qualitative examination of the scope of
problems identified in complex EM, both related and peripheral to the abuse, using content analysis of
narrative case notes of a FCSA. Multidisciplinary teams (MDTs) are a recommended element in PCC,
and are prioritized for replication nationwide. While agreed to be necessary in addressing abuse, there is
no agreed definition of success. To inform strategic replication and develop an evaluation framework,
Chapter IV elicits national perception of drivers and resistors of development and sustainability of MDTs
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from a national panel of experts and a nationwide survey to identify what resources are needed in the field
to support MDT infrastructure, and understand how to measure MDT success. Findings from this research
will inform replication of holistic, person-centered responses to EM, and toward incorporation of outcome
measures that reflect such responses.

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CHAPTER I: INTRODUCTION
Elder Mistreatment Interventions: Defining Success
Four decades after elder mistreatment (EM) was nationally recognized as a social problem, a
kaleidoscope of programs now exist to address EM at various levels. A major hindrance persists: no
interventions have proven effective at ending abuse (Connolly et al., 2015; Stahl, 2015; Pillemer et al.,
2016). Systematic reviews published in the past decade report few intervention studies of methodological
rigor, fewer indicating statistically significant changes, and none that show evidence of eliminating EM or
mitigating the consequences (Ploeg et al., 2009; Baker et al., 2016; Fearing et al., 2017). In part, this is
due to difficulty defining and measuring intervention success. The primary outcome of interest is stopping
abuse in individuals, yet measuring EM prevention is challenging since most cases are never reported
(Jackson, 2016). Although most of the intervention research focuses on risk-reduction as success, and
there is a wide range of variables utilized, statistically significant improvement after intervention is rare,
effect sizes are minimal when it occurs, and none have proven risk reduction is a pathway to reduced
abuse or impact on victims.
A concrete, unified definition of success may not exist because of the heterogeneous nature of
abuse. Causal mechanisms vary across and within abuse type (Jackson & Hafemeister, 2011; Burnett,
Jackson, Sinha, Aschenbrenner, Murphy, Xia, & Diamond, 2016; DeLiema, 2017), and perpetrators fall
into different classification (DeLiema et al., 2018; Jackson, 2016). Standardized measures of risk
reduction or consequence mitigation may not be sensitive to individualized perception of meaningful
change. A recently proposed solution is a measure of goal attainment scaling (GAS) intended to be
person-centered and modifiable for individual goals, with numeric scaling of extent that goals were
completed to allow aggregation (Burnes & Lachs, 2017). While GAS seems promising, it has not
addressed management of conflicting service provider and victim goals, which is a familiar dichotomy in
EM work. Many older adult victims reported to APS do not pursue recommendations (Barker &
Himchak, 2006), and reasons are understudied.
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Participation in EM intervention is voluntary (NAPSA, 2013; ACL, 2016). Victims may prefer
preservation of relationships with their abusers (Jackson, 2016; Heisler, 2018) and subjectively minimize
abuse severity (Burnes, Lachs, Burnette & Pillemer, 2017), so refusal of formal EM services is common
(Lachs & Berman, 2011). Recent research examines processes indicative of victim engagement with APS,
noting the important role of building rapport, victim problem-recognition, and social support (Burnes et
al., 2016). Ending an abusive relationship is difficult for victims, and may require several attempts.
Progress, when it occurs, is often incremental. A theoretical practice model suggests variables indicating
movement along this process, such as therapeutic alliance between victim and service provider,
acceptance of services, and completion of safety plan elements (Burnes, 2017). These theories are yet to
be studied, however, so the impact of these approaches on improving victim well-being and ending abuse
remains unknown.
What do Victims Want?
Victim input on EM intervention approaches has not been systematically elicited, so it is
unknown what extent current remedies offer solutions they find favorable. There is a fair amount of
qualitative inquiry on victim experiences, including one systematic review, and though the majority of
participants are older female victims of domestic violence (DV) or intimate partner violence (IPV)
(Hightower, Smith, & Hightower, 2006; Fingfeld-Connet, 2014), studies on victims of other forms of EM
share similar themes on perceptions of the abuser, reasons for vulnerability, and barriers to change
(Sandmoe & Hauge, 2014; Kumar, 2016; Oliver, Fenge, & Brown, 2015; Baulaurier, Seff, Neewman &
Dunlop, 2007). Both IPV and mass marketing fraud victims said the relationship with their abuser
fulfilled a need for socialization and meaning (Fingfeld-Connett, 2014; Oliver, Fenge, & Brown, 2015;
Kumar, 2016). Most participants did not self-identify as abuse victims, but the situation was recognized
as an emotional strain by those who contacted services for help (Hightower, Smith, & Hightower, 2006;
Sandmoe & Hauge, 2014). Some felt the abuser was a victim of circumstance, especially adult children
(Sandmoe & Hauge, 2014). Barriers to abuse cessation were victim shame, fear of loss of life purpose,
powerlessness, and financial or emotional dependency (Finfgeld-Connet, 2014; Kumar, 2016; Oliver,
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Fenge, & Brown, 2015). Some purported victims would not leave the abuser because of emotional
attachment to their home or loyalty to the abuser, or both. Fear of facility placement was common among
these victims (Hightower, Smith, & Hightower, 2006; Baulaurier, Seff, Neewman & Dunlop, 2007), and
some believed criminal justice efforts would exacerbate the problem, or that victim services were
confusing and not tailored to older people (Baulaurier, Seff, Neewman & Dunlop, 2007).
Though some EM victims experienced reduced self-efficacy because of EM (Kumar, 2016),
others coped by seeking meaning and peace in life despite the abuse through forgiveness, distraction, or
support for their abuser (Finfgeld-Connet, 2014; Sandmoe & Hauge, 2014). Many expressed desiring
informal support from a non-judgmental confidant, particularly another abuse victim, to listen and give
practical advice (Hightower, Smith, & Hightower, 2006). More research is needed, but this literature
suggests the importance of life purpose and social connectivity for EM victims, and that existing
interventions are perceived as inaccessible and alienating at best and at worst, threaten to remove the parts
of life they hold most dear.
Why Person-Centered Care?
In absence of empirical basis for mitigating the impact of EM on victims, theoretical guidance for
intervention can be gleaned from the robust literature on the benefits of facilitating preferences of older
adults. Physical and emotional functioning, memory, and longevity are all improved when choice is
enabled, even perceived choice over a single aspect of the person’s life (Mallers, Claver, & Lares, 2014).
The benefits of agency are attainable despite diminished capacity or dependency, when older adults are
given opportunities to make decisions among comprehensible alternatives. Facilitating older adult
autonomy has potential to improve the lives of EM victims, therefore autonomy and self-determination
are key APS principles (NAPSA, 2013), and person-centeredness is an ethical foundation of practice
(ACL, 2016).
Large variance in health care services proclaiming to be PCC (Kogan, Wilber, & Mosqueda,
2015) spurred development of a consensus definition and structural guidelines; the expert panel who
participated agreed:
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“Person-centered care” means that individuals’ values and preferences are elicited and, once
expressed, guide all aspects of their health care, supporting their realistic health and life goals.
Person-centered care is achieved through a dynamic relationship among individuals, others who
are important to them, and all relevant providers. This collaboration informs decision-making to
the extent that the individual desires. (AGS, 2016, p. 16)
This definition is a helpful beginning in framing PCC in the context of EM intervention. Given a dearth of
grounded research exploring specific intervention approaches preferred by victims, PCC offers a method
of understanding victim preferences on an individual basis.
Complexity of Elder Mistreatment
Providing PCC in the context of EM may have challenges distinct from those in primary clinical
care. Victim perspectives offer a glimpse of the difficulty of resolving EM when victims are dependent on
their abuser for emotional needs, abuse is a lifelong pattern (Jackson, 2016), and isolation and cognitive
impairment complicates the delivery of services (Teresi, Burnes, Skowron, Dutton, Mosqueda, Lachs, &
Pillemer, 2016). Multiple forms and lifetime abuse likely cause cumulative mental and physical illness,
thereby increasing vulnerability, with stronger effect from historical abuse than current (Ramsey-
Klawsnik, 2017; Hamby, Smith, Mitchell, & Turner, 2016). Sustainable abuse alleviation may not be
feasible in most complex EM (Jackson, 2016), particularly given that the APS model has funding
limitations and there are no evidence-based practice guidelines (GAO, 2011; Ernst, et al., 2014). APS
primarily offers short-term case management aimed at addressing crisis, yet some EM victims who resist
intervention or follow-through may need individualized, longer term support (Jackson, 2016).
EM cases exhibit a “continuum of complexity” (Jackson, 2016), yet the range of the concrete case
characteristics associated with EM complexity has not been explored. A measure of EM complexity that
includes a person-centered victim perspective would enhance identification of victims requiring longer
term support, and could inform resource allocation for EM services. Intervention evaluation research
would also be enhanced with knowledge on case complexity to aid in contextualizing findings to the
attributes of cases, and development of an EM complexity case mix index would enhance cross-site
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comparison. Toward understanding EM complexity, victims have the potential to provide valuable
information on the impact of abuse on their lives, and their preferences on needed support (Heisler, 2018).
Likewise, APS caseworkers are valuable informants on the vexing and arduous demands of EM casework
(Ramsey-Klawsnik, 2017). Therefore, both victims and frontline APS workers are valuable sources for
information on case complexity in research (Ramsey-Klawsnik, 2017; Heisler, 2018; Ernst et al., 2014).
Multidisciplinary Teams, A Leading Intervention
Of all EM interventions, there is the greatest body of empirical evidence and anecdotal support
for MDTs (Fearing, et al., 2017). Some MDT models, enhanced with full time staff and availability of
expert consultants providing assessments, have perceived effectiveness among members (Navarro, 2010;
Wigglesworth et al., 2006) and greater efficacy at completing team goals, compared to usual care
(Navarro et al., 2012; Gassoumis et al., 2015; Rizzo, Burnes, & Chalfy, 2015). While it is uncertain if and
how MDTs improve client outcomes, they show potential for improved cohesion across usually siloed
service systems by facilitating cross-agency learning and collaborative casework, and may be a
foundation for productive dialogue and innovation. With broad variance in MDTs structure (Teaster &
Navarro, 2003), and numerous challenges in development and sustainability (Schneider et al., 2010),
outcomes linked to resource-rich MDTs including improved reduction of risk factors, and higher rates of
prosecution and conservatorship cannot be generalized to all MDTs. Nevertheless, high rankings from
team members, conceptual support, and advocacy of subject matter experts (Mosqueda, 2012) have
translated recognition of the importance of MDTs into federal policy (EJA, 2010), and national
replication of MDTs is a first-wave action item in the elder justice strategic plan (Conolly et al., 2014).
The Present Research
Over the past decade, there has been increasing support at the national level for addressing EM,
and several groups of stakeholders agree that improved knowledge of victim preferences and intervention
research are urgent priorities (The Elder Justice Act [EJA], 2010; Connolly et al., 2014; Stahl, 2015;
Breckman, et al., 2015; ACL, 2016). Experts assert that complex cases of EM are increasing, and that EM
warrants a longer term, individualized, therapeutic approach, that includes solicitation of victim advice on
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intervention approaches and available supports (GAO, 2011; Jackson, 2016; Heiser, 2018; Ramsey-
Klaswnik et al., 2017; Hamby et al., 2016). PCC provides a theoretical basis for incorporating victim
preferences into practice (ACL, 2016), and the consensus definition established a promising framework
for adaptation to EM (AGS, 2017). Multidisciplinary approaches, a cornerstone of PCC delivery (AGS,
2016; Bergerson, 2006), are recognized as an important tool for addressing EM. While suggestions on
service elements have been proposed, such as longer-term services, development of rapport, and
multidisciplinary approach (Burnes, 2017; Jackson, 2016), research is needed to establish concrete
guidelines for applying these tools.
Given the complexity of EM and the dearth of scientifically derived knowledge on how to help
victims, including what help they prefer, outcome evaluation may not be practical or useful as the sole
methodology to study interventions. Reliance only on summative outcome evaluation risks erroneous
conclusion about the intervention due to implementation challenges, incorrect attribution of outcomes, or
outcome insensitivity. Formative evaluation enables systematic assessment of the practicality and
mechanisms of innovative programs for which there is no existing evidence base during implementation,
and promotes informed adaptation (Stettler et al., 2006).
The purpose of this dissertation is to broaden the definition of success in EM to include
perspectives from EM victims. This research will provide an empirical foundation for the study and
replication of long-term PCC for victims of EM through examination of an innovative person-centered
elder abuse intervention pilot, a Forensic Center Service Advocate (FCSA). With no prior formative
evaluation, this research is qualitative to enable a thorough exploration of emergent content and
processes. Chapter II is a case study exploration of the delivery of PCC, focusing on facilitative and
inhibitory program elements for eliciting and incorporating client preferences into a risk-reduction case
plan. Toward an objective analysis of case complexity from the lens of PCC, Chapter III uses content
analysis to examine the range of problems identified by the care provider and the victim, including
contextual issues not directly related to the abuse. To aid in the replication and evaluation of MDTs,
Chapter IV provides data from a national study of barriers and facilitators to identify malleable obstacles
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to widespread replication. In addition, the chapter examines success of MDTs as perceived by
professionals and a panel of experts to aid process and outcome evaluation. The goal of these studies is to
inform EM intervention design and evaluation by identifying important structures and processes, and to
lay the groundwork for including what victims want in defining success.

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CHAPTER II
“IT’S COMPLICATED”: PERSON-CENTERED CARE OF ELDER MISTREATMENT

INTRODUCTION
Case 1
Ms. M, aged 94, who lived alone in her own home, had a primary diagnosis of cancer with co-
morbidities of physical and cognitive impairment, a history of falls, skin breakdown and wound infection.
To assist her with shopping, money management, bathing, and toileting, she invited Tom, a man who
lived on the street near her home, to live with her, free of charge in exchange for caregiving. She gave
Tom access to her bank accounts, which he sometimes used for his personal needs. Investigations by
Adult Protective Services (APS) and law enforcement were initiated after reports of two separate accounts
of theft: one for a mysterious four-thousand-dollar withdrawal from her bank account, and a second for a
possibly fraudulent reverse mortgage, which law enforcement halted until her capacity to consent could
be determined. Tom cried during interviews with police and APS and his speech was rambling and
unfocused. Diagnosed at an early age with anxiety and depression, he disclosed self-medicating with
alcohol. Tom fixated on the theft against Ms. M, asserting he was promised the home when she died. Ms.
M became agitated and shouted at law enforcement and APS, insisting she did not need help.
Case 2
Ms. R, aged 68, lived in her own home and received over $10,000 monthly from rental properties.
Diagnosed with mental illness, she had a history of wiring large sums of money to strangers resulting in
multiple reports to APS over the years. Ms. R met Ralph online, and after several months of phone calls
and texts he began requesting money for an international business investment. Although they had not met
in person, Ms. R. referred to him as her fiancé. Ms. R believed Ralph because they spoke several times a
day by phone and text to discuss wedding plans and he showered her with flowers and gifts. Ms. R
planned to sell her rental properties, her sole source of income, to send more money to Ralph. APS
attempted to pursue conservatorship (called guardianship in many states) but investigation by the Office
of the Public Guardian (PG) found that she had decisional capacity.
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Background: Autonomy and Protection in Elder Mistreatment
Elder mistreatment (EM) is a global epidemic. One in ten older people are victimized nationally
each year (Acierno, et. al., 2010), and one in six worldwide (Yon, Mikton, Gassoumis, & Wilber, 2017).
Responses to EM are primarily aimed at improving victim safety, yet as these cases illustrate, victims
may not want help. Self-determination is a fundamental civil right and forcing unwanted change upon
adults, regardless of impairment, is harmful (Mallers, Claver, & Lares, 2014), so the National Adult
Protective Services Association (NAPSA) program standards require victim consent prior to service
provision (2013). Adults are assumed to have decisional capacity unless ruled otherwise by a Court of
law, though ability to make informed choice may be compromised for reasons unrelated to cognitive
capacity, such as distrust or preconceived notions about available alternatives (Bergerson, 2006).
Regardless of capacity, facilitating older adults’ choice improves physical and emotional functioning,
memory, and longevity (Mallers, Claver, & Lares, 2014; Langers & Rodin, 1976), yet there are no
existing guidelines for honoring preferences in those who overtly refuse or who lack capacity. Given
insufficient funding to fulfill their mandate (Benson, 2012), increasing caseloads (GAO, 2010), and a
paucity of evidence-based practice guidelines (Fearing et al., 2017; Ploeg et al, 2019; Baker et al., 2016),
the field grapples with a fundamental question: how do we most effectively help EM victims?
EM intervention offered by APS are typically short-term and focused on alleviating abuse, and if
those in unsafe situations do not desire the help offered, assessing the extent to which they comprehend
the risks. Focus on safety may obfuscate comprehensive understanding of victim desires, especially if
social network, material assets and personal identity are intertwined within EM risk (Smyth, Goodman, &
Glenn, 2006). If given the chance, even older adults with reduced capacity may express individualized
needs and preferences, including safety, that are important to well-being (Mallers, Claver, & Lares, 2014).
Moreover, control is linked to positive outcomes, even perceived control facilitated with outside
assistance (Langers & Rodin, 1976; Mallers, Claver, & Lares, 2014). Person-centered care (PCC) is a
means to incorporate victim preferences and is a guiding ethic in APS policy and practice standards
(NAPSA, 2013; ACL, 2016). Defined as care guided by the individual’s values toward reasonable life
Rowan Dissertation – Fall 2019 20

goals, PCC relies on ongoing elicitation of preferences, best supported by an interprofessional team, a
single case manager, and open communication among all involved (AGS, 2016). PCC is a pathway to
understand what is most important to the individual and identify existing supports toward this, to guide
individualized intervention. A growing body of evidence suggests that using a PCC approach in clinical
settings results in better outcomes (Kogan, Wilber & Mosqueda, 2015a) and lower costs compared to
traditional care (Kogan, Wilber & Mosqueda 2015b).
PCC offers a potentially effective approach for EM (ACL, 2016) yet several barriers offer insight
into why it has not been systematically applied. A central challenge is the predominant culture in which
the provider is the expert and makes decisions (AGS, 2016). Communication between the professional
and client may be additionally strained by victim mistrust of government service providers and the
criminal justice system. Most EM victims do not self-report (Jackson, 2017) from fear that the situation
will get worse or result in undesired punishment of abusers, who may provide social connection and a
sense of purpose (Fingfeld-Connett, 2014; Oliver, Burls, Fenge, & Brown, 2015; Haslbeck, McCorkle, &
Schaeffer, 2012). Although declining help is an explicit preference, it may not be a choice to remain at
risk so much as a refusal of undesirable alternatives, such as facility placement or loss of autonomy
(Oliver, Burls, Fenge, & Brown, 2015; DeLeima, Navarro, Enguidanos, & Wilber, 2015; Fingfeld-
Connett, 2014). While not the intent of the EM response system, placement is a means to assure the safety
of adults who lack capacity (Lachs, 2002).
Current strategies to protect EM victims are informed by a growing evidence-base of EM risk
factors. The Abuse Intervention Model (AIM), a framework for targeted intervention of modifiable risk,
outlines three domains: the vulnerable adult, the trusted other, and the context (Mosqueda, Burnight,
Gironda, Moore, Robinson, & Olsen, 2016). Limited physical or mental capability of the older adult may
cause dependency and inability to self-protect, and if a trusted person is impaired (e.g., mental illness,
substance abuse, physical limitations) there is propensity for emotional dysregulation, physical or verbal
outbursts, exploitation, or neglect. Contextual factors such as isolation or cultural beliefs may normalize
Rowan Dissertation – Fall 2019 21

EM and inhibit help-seeking, yet relationship quality and social networks can be leveraged to mitigate
risk (Mosqueda et al., 2016).
PCC requires understanding the victims’ preferences, yet often preferences are not known. The
present article utilizes the AIM framework to examine how person-centered case management was used
to elicit and address victim preferences and EM risk at initial presentation, over the duration of the
relationship, and the final outcome. Building evidence for EM intervention and examination of victim
preferences are both research priorities (Stahl, 2015; Connolly, 2014; Jackson, 2017), needed to shed light
on approaches to effectively mitigate abuse. PCC is a promising ethical standard recognized by NAPSA,
but without an evidence base it is unknown how or if PCC affects EM victim outcomes. Given the lack of
evidence, this paper analyzes Ms. M’s and Ms. R’s cases to examine how victim preferences were
incorporated into goals toward alleviation of EM risk, and describes the complexities, processes, and
outcomes that occurred, through the lens of the AIM framework.
DESIGN AND METHODS
The purpose of the case studies presented is threefold: first to examine EM victim preferences
and how recognizing and supporting those preferences relates to EM risk; to identify service process and
concrete techniques of PCC applied to EM; to explore elements of the existing response system
conducive and in opposition to PCC. Therefore, each case includes a description of the initial assessment
(abuse risk, psychosocial, health, victim desires, other needs), then case management activities and
additional findings, concluding with outcomes (Budgell, 2008). To explore tensions between EM victim
preferences and risk, the cases selected were those with high EM risk who refused assistance from APS.
Setting
Case studies were drawn from an established Elder Abuse Forensic Center (FC), and were
assigned to long-term case management by a Forensic Center Service Advocate (FCSA). The FC brings
together a multidisciplinary team with weekly review of complex EM, and details on membership,
activities, and outputs described elsewhere (Navarro et al., 2013; Gassoumis et al., 2015; Navarro,
Wysong, DeLiema, Schwartz, Nichol, & Wilber, 2015). FCSA clients include those vulnerable to harm
Rowan Dissertation – Fall 2019 22

and needing support otherwise unavailable, and those who require further assessment to inform FC goals.
For example, some candidates for conservatorship, which often takes months to put in place, are referred
to the FCSA for monitoring and addressing immediate concerns.
The FCSA Intervention
FCSA program elements and procedures were adapted from consensus PCC recommendations
(AGS, 2016), with multidisciplinary support and focus on eliciting client perception of the problem and
preferences to guide case planning. The FCSA participated in FC meetings and received client referrals
recommended by the team. Case management comprised development of a personalized plan, regular
phone and in-person contact, and provision of field-based assistance implementing goals. Intake begins
with an introductory home visit by a service provider with an existing relationship, most often APS, at
which point the FCSA becomes the point of contact for the client, coordinating with other professionals
(e.g., APS, Geriatrician, PG, legal services) toward case goals. The FCSA solicits client preferences by
beginning with the question, “how can I help you?” and incorporates the answer into a care planning
process, including identification of core needs, strengths, risk factors, existing informal and professional
supports, and barriers. Client assessments often occur over several visits focusing on building rapport and
establishing trust. The case plan is additionally informed by the FC team safety goals, with collaboration
and modification of plans as needed. The FCSA works with the client to enlist acceptable services and
supports, including assistance with enrolment, accompaniment on appointments, help with phone calls,
and guidance on problem-solving barriers and developing realistic solutions. When appropriate, the FCSA
assesses others in the home including the suspected abuser to determine supports needed to improve the
client situation. Consultation is sought at FC meetings to support complex decisions on ethical dilemmas,
financial or legal matters, safety concerns, or address changes impacting case goals. For those who refuse
assistance or whose case plans were complete, monitoring is offered to develop rapport and observe
changes, ranging from weekly to monthly check-ins, either in person or by phone.
Sampling Process and Data Collection
Rowan Dissertation – Fall 2019 23

Purposeful theory-led sampling was used to select two cases that reflected tension between client
preferences and FC risk-reduction goals. Criteria were: evident EM risk within multiple AIM domains, a
history of abuse reports and investigations, and client did not outwardly identify as a victim. Data were
narrative notes transcribed by the FCSA, documenting date, modality, and content of each interaction
with or on behalf of the client, including assessment, activities and services, client quotes, goals and case
plan, and other observations or concerns. Identifiers (e.g., names, addresses, phone numbers,) were
redacted. Analysis was conducted in multiple phases. Case identification and preliminary examination of
service approach, process, and outcomes was first completed by two researchers, who then consulted with
the FCSA, FC Project Manager, and FC Director for confirmation and additional insight and context.
Cases were presented to the FC team for discussion on process and outcomes. Approval for the study was
obtained from the University of Southern California IRB. To protect the identities of the individuals
involved in each case, names are aliases, and some details have been omitted or altered, while
maintaining the core case elements.
RESULTS
APS and Law enforcement investigations of financial exploitation were underway for Ms. M and
Ms. R, and their cases were brought to the FC for help on asset protection and, for Ms. M, inadequate
caregiver and Long-Term Services and Supports.
Case 1: Ms. M
AIM Assessment. During the FCSA’s first visit, accompanied by law enforcement and APS, Ms.
M rejected offers for services and repeatedly requested to be left alone. Through the lens of AIM, EM risk
was apparent in all domains. Her confusion about the financial exploitation allegations indicated cognitive
impairment and inability to self-protect. Ms. M’s physical condition and neglect of health care was
especially concerning, with skin wounds, swollen feet that appeared to require medical attention, and a
history of falls. Ms. M was combative with service providers and investigators, a characteristic that could
make care provision difficult. Her caregiver, Tom, was also impaired with history of mental illness,
substance abuse, and emotional instability. Tom provided personal care and oversaw Ms. M’s finances;
Rowan Dissertation – Fall 2019 24

her income was less than $1000 per month. Tom described feeling smothered and was especially
uncomfortable providing bathing assistance but was dependent upon Ms. M for housing. To address her
falls he removed rugs, but the falls persisted. Contextually, Ms. M was isolated with no interest in
socializing or leaving her home. EM risk was apparent on the first assessment, but strengths in Ms. M and
Tom’s relationship were gleaned over subsequent visits and calls which spanned several months. It
became clear the friendship was mutually caring; Ms. M had known Tom as a child in her neighborhood
and wanted to support him by providing housing. Despite the stress, Tom was caring and harbored no
apparent resentment for Ms. M’s difficult behavior.
Preferences. Ms. M’s most ardent desire was to remain in her home, and Tom made this
possible. However, the arrangement left Ms. M vulnerable to financial exploitation and her physical
condition was deteriorating from neglected health care.
Case Plan. The FC team’s plan was to assist investigation of the financial crimes against Ms. M
and the FCSA focused on addressing malleable risk by supporting Tom as a caregiver and suggested other
assistance. Ms. M approved respite care for Tom, was persuaded to see her physician to address health
issues, and accepted help obtaining financial assistance with utilities and a fall alert system.
Case Management. Despite the initial agreement, Ms. M reverted to refusing help, cancelling
doctors’ appointments because of fear of placement in a facility, and declining the fall alert system after
learning about the cost. Tom could not follow through with the paperwork required for respite care. Ms.
M often failed to recognize the FCSA or recall conversation that had taken place hours prior; at times she
was immobile. She slept on her couch and went days without bathing or changing her clothes. Tom was
often unavailable. After the FCSA helped Ms. M understand that neglecting her medical care was more
likely to cause placement and further reports to APS, Ms. M finally agreed to visit the doctor; Tom and
the FCSA went with her. As anticipated, the physician was concerned about Ms. M’s deteriorating
condition and initially suggested facility placement, but recanted after hearing the FCSA’s plan for
caregiving support and fall prevention. Subsequently, Ms. M’s hygiene showed a marked improvement
and she accepted respite care after assurances that she would dictate the caregiver’s schedule. Options
Rowan Dissertation – Fall 2019 25

were explained in terms of the impact on her desire to remain in control and in her home, motivating her
agreement to medical care and respite. Similarly, Tom’s need for housing coupled with the FCSA
recognition of the constraints he faced, helped motivate him to improve Ms. M’s care. When other
providers became involved, the FCSA advocated for Ms. M’s preferences to remain at the forefront.
Team Involvement. The financial abuse allegations of theft and mortgage fraud initially
presented to the FC were found by the team to lack evidence, so Ms. M’s law enforcement and APS cases
were closed. The FC team offered guidance to the FCSA when issues and concerns arose. Tom requested
advice regarding a caller threatening to foreclose the home, to whom he had sent several checks, so the
FCSA referred to APS for a new investigation. APS was able to investigate the fraud with assurance that
other concerns were under FCSA monitoring and care. The caregiving situation continued to be far from
ideal. Ms. M’s falls persisted, resulting in at several trips to the emergency department. She was given a
fall alert pendant, but could not remember its purpose. Tom disclosed a recent hospitalization and
diagnosis with cirrhosis of the liver after mixing alcohol with Ms. M’s pain medication. The FCSA
brought the case back to the FC team to discuss how to address Tom’s questionable ability to oversee Ms.
M’s care, her severe memory lapses, and danger of continued injury. The team recommended a cognitive
and capacity assessment by the FC geriatrician.
Outcomes. The FC geriatrician’s cognitive assessment found that Ms. M lacked capacity, and a
referral for conservatorship was filed to the Office of the Public Guardian (OPG). Though Tom appeared
to the OPG investigator as a possible conservator, the FCSA disclosed his substance abuse, emotional
volatility, and lack of proper care in the past. Months later, a niece was identified as a suitable and willing
conservator to assist with finances and care decisions. Tom, who continued as her caregiver, regularly
discussed Ms. M’s care with the FCSA, notifying her when Ms. M was enrolled in hospice. Ms. M
continued to receive visits from the FCSA and appeared accepting of her closeness to death. On the
FCSA’s final visit, Ms. M was sleeping in a hospital bed in the living room and Tom tearfully described
burial preparation and plans to move after her death. Ms. M passed away a few days later, with three
hospice nurses and Tom by her side; she was buried next to her husband.
Rowan Dissertation – Fall 2019 26

Case 2: Ms. R
AIM Assessment. On her first visit with APS, the FCSA was greeted by Ms. R with enthusiasm
as she eagerly described her wedding plans and showed the FCSA her gown and ring, explaining the
wedding was postponed “because of Ralph’s work.” She responded to questions about Ralph’s credibility
with irritation and insistence that he was not a fraud; she referenced her past victimizations to demonstrate
her knowledge on scammer techniques, insisting Ralph was different. Appling AIM, Ms. R was
vulnerable to exploitation with impaired judgement and multiple mental health diagnoses including
anxiety, depression, bipolar disease, and schizophrenia. After the first meeting with the FCSA, Ms. R was
hospitalized for prescription overdose resulting in seizures and falls. She admitted to a history of suicide
attempts but denied feeling depressed. Ms. R had no previous marriages and no immediate family, and
her social network consisted entirely of hired professionals, referred to by her as “friends”. She had daily
contact with her financial advisor’s wife, who monitored her financial transactions and withdrew money
without consent, and a caregiver, who helped manage her medication. Ms. R’s rental properties provided
a monthly income of more than $10,000, from which Ralph, and the FC suspected her “friends”, were
personally benefitting. Contextually, Ms. R’s isolation and lack of alternate social network increased her
risk of continued financial exploitation. However, her staff had earned her trust with over 20 years of
consistent service and support, and welcomed the FCSA’s assistance with concern about the effect of
Ralph’s continued delay of the wedding on Ms. R. They were also key to Ms. R’s ability to manage her
finances as she declined to share her financial statements with the FCSA or an alternate fiduciary,
explaining that her “friend” helped reduce thousands of dollars in debt years prior.
Preferences. Ms. R’s desires made her vulnerable to exploitation: she wanted intimacy, and
Ralph provided a form of romantic attention and comfort she was not getting elsewhere. She relished the
daily contact and gifts. By the second visit with the FCSA, it became apparent she also craved respect.
Despite her protectiveness of her staff, Ms. R expressed frustration with their scrutiny of her spending and
affairs, and failure to honor her decisions. She enjoyed shopping and did not want her purchases
questioned. She also wanted to get a driver’s license, which they had refused.
Rowan Dissertation – Fall 2019 27

Case Plan. The FC team’s goal was to protect Ms. R’s finances; the FCSA case plan began with
agreeing to periodic visits and calls and exploring ways to reduce dependency on her “friends”. Per her
request, the FCSA agreed to accompany Ms. R to the doctor and escort her to the DMV for a driver’s
license.
Case Management. Accompanying Ms. R to the doctor and DMV provided insight into her
relationships with Ralph and her staff. The doctor confirmed her ability to drive and expressed concern
that her attendants were exploiting her. On the ride home, Ms. R admitted her fear that confronting her
staff would cost their friendship. The FCSA suggested communication strategies for establishing
boundaries in a non-threatening manner, and Ms. R showed interest. Also, after three months of weekly
visits, Ms. R disclosed that while the daily attention from Ralph gave her joy, distance was part of his
appeal; she feared men based on a past relationship that became physically violent. This private
information suggested that Ms. R had greater insight into the nature of the relationship than it initially
appeared. Shortly after, a new EM report anonymously placed to APS prompted a home visit from APS
and law enforcement. Saying that she felt disrespected and did not want investigators or county
employees in her home, Ms. R refused further communication with the FCSA. However, one of Ms. R’s
staff contacted the FCSA for help and offered copies of Ms. R’s bank statements. Given Ms. R’s refusal
of services and ethical questions over financial information provided without her permission, the FCSA
turned to the FC team for consultation.
Team Involvement. APS closed Ms. R’s case after the FCSA became involved because her
intact capacity and unwillingness to end the relationship with Ralph precluded their ability to intervene.
However, APS remained a valuable resource to the FCSA at FC meetings and by email, sharing helpful
insights from the long history of prior reports. Ms. R’s case was discussed among the FC team for
analysis of the financial documents provided to the FCSA, which revealed Ms. R’s unwitting
participation in money laundering on behalf of Ralph. Without realizing it, she was committing a crime.
Despite having lost contact with the client, the FCSA communicated with Ms. R’s staff to protect her
finances.
Rowan Dissertation – Fall 2019 28

Outcomes. Once Ms. R’s trust was damaged, she withdrew from contacting anyone but her staff,
who continued to report concerns and updates to the FCSA. With their help, money transfer agencies
were notified of the suspicious money laundering activity, enabling an alert to block future transfers.
Although Ms. R’s relationship with Ralph continued, her case was closed when nothing more could be
done; her staff agreed to contact the FCSA as needed.
DISCUSSION
These cases shed light on the complexity of honoring preference of high-risk EM victims. Using
case study analysis, this paper described the FCSA program, an intensive case management intervention
designed to provide person-centered wrap-around services to support and expand APS and the services of
a FC team. PCC is sometimes at odds with financial and personal safety, examined here with AIM as a
conceptual model for evidence-based EM risk factors. As depicted in the case studies, both clients were
socially isolated, had constructed a support system that raised concerns about EM risk, and were resistant
to engage additional help because tradeoffs compromised their sense of agency and personal priorities.
Ms. M refused to see a doctor for fear she would be placed in a facility. Ms. R. declined additional
financial oversight and asserted her desire to spend as she pleased. Initially, preferences seemed to
increase EM vulnerability. Ms. M enjoyed Tom’s company and entrusted him with her caregiving needs
and financial management despite his mental illness and substance abuse. Seeking intimacy and romantic
attention, Ms. R gave thousands of dollars to Ralph, and possibly substantial sums to her staff as well, to
ensure their friendship. However, Ms. M and Ms. R were attempting to address common psychological
needs, such as socialization and autonomy, in the best way they could manage. Safety is just one domain
of psychological wellbeing (Smyth, Goodman, & Glenn, 2008), and as Ms. R’s case shows, is
individually defined. The scant research on preferences of EM victims is qualitative and aligns with
themes in these cases. Interactions with scammers may provide meaning and social connectivity that is
difficult to relinquish (Oliver, Burls, Fenge, & Brown, 2015; Finfgeld-Connet, 2014), and assistance for
an impaired abuser may be preferred over ending the relationship (Hightower, Smith, & Hightower,
2006). One study found, in a sample of 64 abuse victims, that many wanted a confidant to listen, affirm
Rowan Dissertation – Fall 2019 29

their feelings, and give practical advice and support (Hightower, Smith, & Hightower, 2006). These cases
demonstrate that focus on enhancing the victim’s perspective of what is working and facilitating their
wishes is a means to reducing EM risk.
Specific techniques for honoring preferences were somewhat outside traditional EM intervention
approaches. Rather than addressing risks directly, the FCSA assisted on tasks identified or approved by
the client enabling continued contact and establishing trust. Over time it was learned that the preferences
were not as irrational as they first appeared and met their needs for intimacy and assistance. Tom’s
assistance permitted Ms. M to remain in her home, and Ms. M enjoyed a romantic relationship without
fear of physical harm. Psychological needs met through Ms. R and Ms. M’s high-risk arrangements were
not initially disclosed to the professionals responding to EM reports. Relationship-building and slowly
developing trust was essential before each woman’s motivations and contextual strengths were revealed.
Support in areas outside the EM risks, such as accompanying Ms. R to the DMV to obtain a driver’s
license helped forge the trust needed for her to share her motivations and underlying fears, information
that was pivotal for making modest adjustment to address risk. Moody (1998) describes the notion of
“negotiated consent” as a process in which autonomy and paternalism are not dualistic but work in
concert such that oversight and assistance support actualization of preferences. These cases offer
examples of negotiating consent. For instance, helping Ms. M understand that her plan to remain at home
by avoiding her physician increased her chances of requiring institutional care, whereas regular medical
treatment could help her remain in her home. The most complex cases may require long-term relationship
building, providing valued services and supports, and ongoing monitoring.
A key intervention for both was assisting a less than optimal support system. Tom was supported
in his caregiving role with education and respite. Similarly, the FCSA worked with Ms. R’s staff on how
to provide effective oversight with connection to service systems. Suspected abusers, including caregiver
neglect may not be included in supportive EM interventions, yet in some situations this approach may be
in alignment with victim preferences and more conducive to sustainable risk reduction (Oliver, Burls,
Fenge, & Brown, 2015; Finfgeld-Connet, 2014; Hightower, Smith, & Hightower, 2006; Smyth,
Rowan Dissertation – Fall 2019 30

Goodman, and Glenn, 2006). Some suspected abusers may be well-intentioned, and others may be
dangerous (DeLeima et al., 2018; Jackson, 2016), so difficult decisions on if and how abusers are to be
supported may be best accomplished with deliberation of an experienced EM MDT. EM cases often
include ethical challenges, and many also require legal and financial expertise or medical evaluation
(Navarro, et al., 2010), our results suggest MDTs are an important component.
Some existing EM interventions were not inherently facilitators or barriers to PCC, but had
potential for alignment with the principles, when supported by FCSA and team coordination. Mandated
reporting is a controversial EM intervention. While understood by many in the EM response system to be
an important tool in aiding awareness and detection of EM risk in vulnerable adults who are unable to
self-protect, others assert it may undermine preferences and even safety of autonomous adults (Jackson,
2017; DeLeima, Navarro, Enguidanos, & Wilber, 2015). We find these concerns may be addressed with
PCC when coordinated with existing efforts. For example, Ms. M’s suspected fraud victimization was
investigated by an APS caseworker who was informed on case progress by the FCSA. Despite risk in
other areas, the investigator knew health and caregiving concerns were already being addressed to the
extent possible. Alternately, Ms. R was reported to APS by an anonymous source, and response was not
coordinated. Though all were well-intentioned, trust is fragile and can be easily eroded. However,
mandated reporting enables trained professionals to approach those unable or unwilling to seek help on
their own. Perhaps the question is not whether mandated reporting should be utilized in EM, but how to
best respond.
Conservatorship is another common EM intervention with contentious aspects potentially
assuaged by PCC. Both Ms. M and Ms. R appeared unable to self-protect, and were assessed by a
geriatrician. Ms. M was found to lack capacity and the team recommended referral for conservatorship.
Conservatorship is a blunt instrument and for Ms. M, may have resulted in what she feared most-
placement; FCSA advocacy helped assure that her desire to remain at home was honored. Ms. R was
deemed to have financial capacity to make decisions about how to spend her money, and continued her
relationship with Ralph, while her staff sought help from the FCSA to curb Ms. R’s unwitting criminal
Rowan Dissertation – Fall 2019 31

accomplice. The FCSA and the team were able to honor each woman’s wishes, while monitoring the
situation and adjusting supports to enhance safety within the parameters of client preference.
Policy and practice implications of this study are significant. Intervention informed by the abuse
victim’s preferences may invert core assumptions. Criminal justice response to EM may oppose some
victims’ preferences. It may be useful to create stronger collaboration between APS and agencies with
advocacy-focused services such as the Ombudsman or domestic violence assistance to incorporate
strategies for supporting victim desires that include EM risk. Reasoned choice includes some evidence
that the person comprehends risks and can weigh possible outcomes. This decisional process rather than
what is decided should guide the assessment of the person’s capacity. Some victims with capacity will
make poor decisions and some will require help and support to carry out the decisions they make
(Bergerson, 2006).
Little is known about the desires of EM victims, and a promising framework for addressing
complex needs and personal desires is the Full-Frame Approach (Smyth, Goodman, & Glenn, 2006).
Offering a comprehensive social service paradigm for those with multiple interwoven problems, the Full-
Frame Approach is a set of principles that incorporates internal motivations, relational context, and care
recipient’s definition of the problem such that solutions are individualized, sustained, and person
centered. The EM response system was built with intent to protect vulnerable older adults from harm.
Although abuse victims with capacity retain the right to refuse services, whereby no services are forced
on capable adults, it is not clear that most interventions are informed by victim preferences. The influence
of choice on physical and mental wellbeing persists regardless of capacity, so consideration should be
made for victim preferences and desires even those who lack capacity.
This paper highlights several key areas for future research. First, it is essential to study responses
to abuse reports. Future research could help tailor response based on case typology and context,
identifying those more effectively addressed collaboratively to build on, rather than compromise existing
relationships. Similarly, assisting EM perpetrators could be informed by perpetrator classification
research, for evidence-based assessment of those appropriate for support, such as distressed caregivers
Rowan Dissertation – Fall 2019 32

(DeLiema et al., 2018; Jackson, 2016). This paper demonstrates that relationships are important, and
social isolation is a top risk factor of EM (Mosqueda et al., 2016; Pillemer et al., 2016), so research is
needed to examine effective approaches to enhance connectivity for EM victims both within and
supplementary to their existing social networks, even those with inherent EM risk. More work is needed
to understand the role of service providers in supporting not just safety, but all areas of wellbeing, as
defined by EM victims.
What is a success in an EM case is not clear. From a PCC perspective, outcomes in the two cases
were reasonable, though EM risk was only minimally reduced. Ms. M did not receive consistently
adequate care; Ms. R’s romantic involvement came with a cost of thousands of dollars, and her need for
friendship left her vulnerable to manipulation. Focus solely on risk reduction as an outcome may overlook
other important benefits of facilitating victim preferences and self-efficacy. To measure success, it may be
necessary to examine other domains of wellbeing in addition to safety, allowing victims to weight which
domains are most important, with individualized interpretations within the context of their relationships,
living situation, and culture. The AIM framework is a helpful starting point, but grounded theory research
should examine favorable outcomes from victim perspectives, for greater clarity on tradeoffs EM victims
are asked to make in exchange for safety. Toward this, Goal Attainment Scaling (GAS) is useful tool to
elicit and track completion of case goals (Burnes & Lachs, 2017), and may additionally aid quantification
of PCC success, especially for cases in which significant risk reduction runs alternate victim preferences.
Finally, processes and structures most conducive to provision of PCC need further study. Our work
suggests that for complex cases, strong communication skills, longer term case management, and
specialized training to support PCC, needs to be systematically tested.
CONCLUSION
Recognizing and designing approaches to address PCC barriers are important steps in developing
effective interventions. Though the cases described in this paper are highly complex and the usual
response system was unable to help, PCC has potential to benefit all EM victims. By pulling the focus
back from safety to a more comprehensive sense of how risky situations are also meeting basic needs,
Rowan Dissertation – Fall 2019 33

there is opportunity to design solutions that are acceptable to victims and may be more sustainable.
However, implementation of PCC will have the challenges. Emotional strain for those working one-on-
one with victims is difficult at best, but focusing on victim preferences and working within risks may be
additionally difficult. It is uncertain to what extent EM interventions can respond to victim preferences,
philosophically and structurally. Person-centered approaches such as the FCSA program have potential to
both elicit and understand victim preferences, to inform existing investigative and service infrastructure.
To implement PCC into EM response, GAS provides a format for eliciting preferences of victims, and
may be adaptable to enable assessment of the extent to which interventions align with victim preferences.
Recommendations for PCC emphasize the importance of trusting relationship and ongoing
communication between provider and client (AGS, 2016; Bergerson, 2008), so APS current short-term
case management approach may leave few options between doing too little—allowing a vulnerable elder
to remain in harm’s way—and doing too much—addressing risk at the expense of the victim’s preference
(Wilber, 1991). More research is needed, especially that which elicits and seeks to understand
perspectives of EM victims, in addition to willingness to critically examine current practices, to assure we
are not harming those we seek to help.

Rowan Dissertation – Fall 2019 34

CHAPTER III
“WICKED PROBLEMS”: AN EXPLORATION OF ISSUES CONCURRENT
TO ELDER MISTREATMENT

INTRODUCTION
Elder mistreatment (EM) is known for being an intractable problem. Increasingly, complex cases
challenge a response system offering short-term, crisis-oriented support (GAO, 2011). Multidisciplinary
Teams (MDTs) that seek to address difficult EM cases with a coordinated, team approach (Ploeg et al.,
2009; Fearing et al., 2017; Navarro et al., 2010), are prioritized for replication and research (EJA, 2010),
and national leadership is burgeoning (Breckman, 2015). Interest in post-investigative services such as
long-term person-centered case management (GAO, 2011; Ramsey-Klawsnick, 2017) and calls for
improved understanding of the continuum of services (Jackson, 2016) show recognition that
supplementary services are needed to adequately address the most complex EM. However, to date, EM
complexity, which has been described anecdotally, lacks research with which to develop an objective
measure. An empirically-based assessment of the nature and components of EM complexity would inform
the development of more effective interventions.
Though lacking a precise definition in EM, complexity is characterized by factors challenging to
investigate and resolve, such as multiple abuse type or multiple perpetrators, cognitive decline,
intellectual disability, mental illness, and substance abuse of victim and perpetrator (GAO, 2011;
Ramsey-Klawsnik, 2017). These overlap with EM risk factors (Pillemer et al., 2016) but complexity is
conceptually distinct from risk with inclusion of ecological aspects contributing to difficulty investigating
or resolving EM, rather than the isolation of independent abuse predictors. Complexity is defined by
interrelatedness of issues, including risk, but also cooccurring circumstances and problems identified by
the victim that may impact attempts at intervention. An empirical foundation of the range of these
concrete elements will inform quantification of complexity, aid case selection for specialized intervention,
and lead to more accurate case comparison in evaluation research.
Despite the broadly recognized challenge of EM complexity, we are aware of no systematic
investigation of the range and interaction of contributing circumstances. Without systematic
Rowan Dissertation – Fall 2019 35

measurement, case selection for more intensive intervention such as MDTs and long-term case
management is subject to bias, compromising program success and evaluation. Objective measures of
complexity will aid policy makers and service providers in quantifying the specific issues cooccurring
with EM locally and nationwide, to estimate amount and type of resources required for tertiary
prevention. To begin to develop such a measure in the absence of prior investigation, this study uses
qualitative content analysis with an inductive grounded theory approach, to enable both exploration and
quantification of emergent case elements for use in developing questions and hypothesis in future
investigations (Padgett, 2012). The purpose of this research is to aid knowledge of EM complexity by
identifying the scope of issues both related and peripheral to EM, through qualitative analysis of narrative
documentation of long-term, person-centered case management for EM victims.
METHODS
Design
This qualitative study was a secondary analysis of an MDT’s case files narrative assessments and
services provided. Notes were redacted of identifiers and coded by two investigators for problems
concurrent to abuse allegations. This work was approved by the University of Southern California’s
Institutional Review Board.
Setting and Participants
The Forensic Center Service Advocate (FCSA) is a pilot program aimed at providing field-based
case management for EM victims, using a person-centered approach to elicit client perspectives and
incorporate them into a holistic case plan. As an extension of services provided by an established elder
abuse forensic center (FC), an EM MDT that reviews complex EM (Navarro et al., 2010; Navarro et al.,
2014; Gassoumis et al., 2015), referral for FCSA assistance is determined by FC members during case
review, and the introduction is coordinated with team members already involved; most often this is Adult
Protective Services (APS). Services begin with rapport development, psycho-social assessment, and
determination of goals, processes often conducted over multiple visits and phone calls. Goals identified
by the client were central to the case plan and activities, even when peripheral to EM risk. When goals
Rowan Dissertation – Fall 2019 36

could not be determined, the FCSA conducted monitoring and worked to initiate the FC team’s
recommended plan for risk-reduction. Activities included assistance with service enrollment,
accompaniment to appointments, advocacy for client wishes, and other support as needed. Once the
FCSA case plan was complete with no other goals identified by the client or FC, then follow-up
monitoring was offered periodically by phone and in-home visits. Services were closed if the client
refused assistance, or activities were completed, and no identified safety risk remained. Cases brought to
the FC for specialized consultation are among the most difficult situations, and many had multiple forms
of abuse and prior history with APS (Navarro, et al., 2014). Criteria for FCSA referral were the victim
needed support to achieve FC case goals, and/or apparent vulnerability with no immediate remedy. The
pilot phase, which was funded for a part-time FCSA from July 2015 to April 2018, received 99 clients.
Phase two of the program is underway, and expanded to support a full-time FCSA. Data for this study is
from the pilot, and inclusion criteria were service or visitation acceptance.
Data Collection
Purposeful case sampling of the earliest clients was conducted to focus on those with longest
duration of involvement and greatest documentation volume. Demographics and abuse type were
collected from FC intake forms, submitted by the case presenter prior to the initial meeting in which
referral occurred. The FCSA transcribed a case note, narrative documentation after each activity, detailing
the purpose and content of each contact with or on behalf of the client. Date, modality (e.g., in-person, by
phone, email, written correspondence), FCSA perceptions, and next steps were included. Assessments
were unstructured observations of client psychosocial factors, physical condition, living environment,
safety risk, desires, quotes by client and others involved. Investigation findings and services by other team
members were also included, when available.
Analysis
Inductive content analysis of case notes was conducted by two researchers using QSR
International’s NVivo 12 software. Case narratives were reviewed and independently coded for issues
concurrent to EM, with meetings to discuss findings and reconcile codes after every three cases reviewed.
Rowan Dissertation – Fall 2019 37

After 6 cases were coded, all themes were reviewed by the two investigators and grouped. These codes
were then applied to 22 cases, at which point thematic saturation of main code groups had been reached.
Final code list was then applied to all cases, from which code agreement comparison was calculated.
RESULTS
Participant Characteristics
FCSA clients included in this study were referred between July 23, 2015 and August 16, 2016.
Two were excluded because the FCSA had no interaction with the client; one died two weeks after
referral and assistance for the other was provided through an FC member; the client declined FCSA visits
or phone contact and had adequate support from family. Of those included (n=22), the majority was
female (72.7%) with average age 77 (SD=12.6), and one fifth were dependent adults younger than age 65
(22.7%). Over half was Caucasian (54.5%), over a fifth African American (22.7%), three were Hispanic
(13.6%), and one Asian. Almost half lived alone (45.5%), over a third lived with family, including adult
children (18.2%), spouse (4.5%), and other family (18.2%). Almost one-fifth lived with non-family
(18.2%). The majority of the participants had physical and cognitive impairment. One half had mild
physical impairment (45.5%), almost one fourth were moderately to severely disabled (22.7%), and most
exhibited mild (27.3%) or moderate-severe (45.5%) cognitive impairment. Almost half of participants had
more than one form of abuse (45.5%), 45.5% financial exploitation, 45.5% self-neglect, 27.3% neglect,
and 27.3% psychological. Six (27.3%) were self-neglecting, with no abuser. One third of participants
were abused by family (31.8%), 27.3% by non-family who was well-known to the victim, and 13.6% by
strangers. Almost two-thirds (59.1%) had a history of APS recurrence.
Rowan Dissertation – Fall 2019 38

Issues Concurrent to Elder Mistreatment
Broad thematic groups emerged from numerous diverse content codes: Caregiving, Health,
Preferences, Cognitive, Behavioral Health, Financial, Health and Community Services, Social, Safety,
Housing, Transportation, Caregiver, and Abuse, depicted in table 3.2; ten of these had sub-themes. The
majority of cases reviewed had multiple different issues, with a mean of 15.9 (SD=7.3) and maximum of
28 distinct issue codes in one case.
Table 3.1. Sample Characteristics (n = 22)
Age (m, SD)
<65 5 (22.7%)
Female 16 (72.7%)
Race and Ethnicity
Caucasian 12 (54.5%)
African Americn 5 (22.7%)
Hispanic 3 (13.6%)
Asian 1 (4.5%)
Other 1 (4.5%)
Living Status
Alone 10 (45.5%)
Adult Children 4 (18.2%)
Non-Family 4 (18.2%)
Other Family 3 (13.6%)
Spouse 1 (4.5%)
Physical Impairment
Mild 10 (45.5%)
Moderate - Severe 5 (22.7%)
Cognitive Impairment
Mild 6 (27.3%)
Moderate - Severe 10 (45.5%)
Abuse Type
Financial 10 (45.5%)
Self-Neglect 10 (45.5%)
Emotional 6 (27.3%)
Neglect 6 (27.3%)
Multiple 10 (45.5%)
Self-Neglect, only 6 (27.3%)
Abuser
Family 7 (31.8%)
Stranger 3 (13.6%)
Non-Family 6 (27.3%)
No Abuser 6 (27.3%)
Recurrent APS 13 (59.1%)
76.9 (12.6)
n (%) Variable
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Table 3.2. Issues Concurrent to Abuse and Neglect
Sub-Theme Definition
Cargiving 20 (90.9%) Caregiving description, including emotional tension of caregivers, need for caregiving, and caregiving services
Caregiving needs 18 (81.8%) Needing assistance with ADLs or IADLs, observed by inadequate hygenie, urine or feces, inability to dress appropriately or
prepare meals, and cleanliness of the home. Includes those who are receiving help if additional assistance is needed
Caregiving provided 14 (63.6%) Receiving assistance with ADLs or IADLs, including incontinence care, bathing and hygenie, dressing, meal preparation, and
house cleaning, transportation, financial management, companionship, and home delivered meals
Conservatorship 10 (45.5%) Discussion of public guardian referral, investigation of and filing for conservatorship, or appointment of conservatorship
Health 20 (90.9%) Any health symptoms, diagnoses, injury, or other physical ailments
Physical limitations 12 (54.5%) Physical impairment or assistance for, including hearing or vision limitation
Pain 11 (50.0%) Experiencing, or being treated for, pain
Injury 10 (45.5%) Physical injury including scrapes, bruises, or other physical trauma
Hospitalization 10 (45.5%) Client is hospitalized
Fall 9 (40.9%) Falls or indication of fall risk
Illness 8 (36.4%) Symptoms, signs, or feelings of being sick or other short-term physical ailments such as infection, dizziness, loss of appetite,
insomnia, or rash
Diagnosis 7 (31.8%) Chronic illness diagnoses, and details about
Incontinence 5 (22.7%) Client smells of urine, needs or uses adult diapers
Heart attack or stroke 4 (18.2%) Historical account or current, including discussion of effects from such as impairment, medical treatment, etc.
Died 4 (18.2%) Death of client
Difficulty breathing 2 (9.1%) Difficulty breathing, shortness of breath, and/or medical treatment for
Surgery 2 (9.1%) Mention of surgical procedure, repercussions related to, or physician recommendations for surgery
Preferences 20 (90.9%) Any stated preferences of the client describing life wishes, services, or intervention, including refusal of help
Decline Assistance 18 (81.8%) Declines informal assistance or formal services
Consent 18 (81.8%) Consenting to offers, intervention, or other supports
Perspectives 18 (81.8%) Describes desires, wishes, or frustrations
Cognitive 19 (86.4%) Implied or admitted memory lapses or forgetfulness, inability to understand complex tasks or planning
Behavioral Health 18 (81.8%) Descriptions or exhibitions of mental health symptoms, diagnoses, or treatment
Depression 10 (45.5%) Client appears, describes feeling, or reliable sources report they are feeling depressed
Mental Illness 9 (40.9%) Diagnosis, discussion of history of, or observed symptoms, including illogical or delusional thinking, paranoia, innaproprate
responses, excessive self-defeating behavior, suicide attempt, extreme combativeness, emotional instability
Anxiety 6 (27.3%) Symptoms or client expression of feeling anxious
Combative 5 (22.7%) Client is argumentative and combative, exhibited by swearing, accusations, or insults
Substance abuse 5 (22.7%) History of or current substance abuse of alcohol, over the counter medication, or others
Hoarding 4 (18.2%) Home is cluttered to the extent that it impacts client's mobility and usage of living spaces
Financial 16 (72.7%) Problems with finances, including assistance needed obtaining money or with related tasks (bill-pay, etc.)
Financial oversight 15 (68.2%) Needs or receiving help with financial oversight/paying bills or addressing debt. Also includes help with insurance, vehicle,
and taxes
Needed 10 (45.5%) Mis-managed finances and other demonstrations of need for assistance, observed and explicit requests by the client
Provided 9 (40.9%) Descriptions of assistance managing financial matters, both formally (attorney, financial planner) or informally (friend, family)
Low income 14 (63.6%) Needs money for basic needs
Health and Community Services 15 (68.2%) Health or social service needs or issues with, including barriers to service access
Access 11 (50.0%) Challenges accessing needed or desired health care, social services, or other supports needed for quality of life
Medication problems 8 (36.4%) financial, noncompliance, incorrect prescription, or other issues regarding prescription drugs
Poor quality service 6 (27.3%) Services quality is below reasonable expectation, including lateness or inadequate attention to client needs and requests
Oppose client wishes 3 (13.6%) Service provider disagreement, or failure to accomodate, with client's stated prefereces
Social 13 (59.1%) Issues related to socialization
Isolation 7 (31.8%) Signs of deteriorating social system (e.g., familial estrangement, friends dis-engaging), unwillingness or inability to engage in
social connection
Social Support 7 (31.8%) Current social connection and supports
Safety 13 (59.1%) Immediate threats to client's physical or financial safety, both related and outside the alleged abuse or self-neglect, observed
by the FCSA or described by the client or others involved with the case. Includes client being or threatening safety of others
Housing 11 (50.0%) Change in residence, issues with neighbors, housing instability, and other circumstances related to or impacting housing
Housing issues 9 (40.9%) Risk or loss of housing
Facility placement 8 (36.4%) Client is permanently placed in a long term care facility, discusses moving to a facility, or a professional reccomends moving to
a facility
Neigbor/landlord conflict 4 (18.2%) Arguments or aggression between client and their neighbors or disputes with housing management (e.g., landlord, HOA)
Transportation 11 (50.0%) Needing or recieving transportation assistance, or other occurences related to loss of independent transportation (e.g., loss of
drivers license)
Caregiver 10 (45.5%) Issues related to the client's caregiver
Caregiver tension 7 (31.8%) Hostile behavior, resentment, or fear between client and current caregiver, including exhaustion or frustration with caregiving
responsibilities, and client being infantalized. Informal and formal paid caregivers
Caregiver impairment 2 (9.1%) Any physical, cognitive, or mental/emotional issues exhibited by the caregiver that limits, or potentially limits, their ability to
provide care
Abuse 10 (45.5%) References to abuse the client experienced prior to the current abuse
Current Abuse 7 (31.8%) Incidents of abuse by another, observed by or reported to FCSA, including those under investigation and new discoveries
New Allegations 5 (22.7%) New reports of abuse, suspected or confirmed
Abuse History 4 (18.2%) References to abuse the client experienced prior to the current abuse; may include early life incidents and history of elder
n (%)
Rowan Dissertation – Fall 2019 40

Caregiving. Most cases (90.9%) needed some form of care, observed through assistance
provided and challenges or inability to complete activities of daily living or instrumental tasks. Sub-
themes were Caregiving Need, Caregiving Provided, and Conservatorship.
Caregiving Needs included needing assistance with toileting, meal preparation, bathing, dressing,
housekeeping and other daily activities. Toileting included incontinence, evident from urine or feces
visible on the client or in the home. Meal preparation and feeding help were needed and some were
unable to safely operate kitchen appliances. Poor hygiene was observed as odor and dirt on the body and
nails. Some lacked the insight or physical ability to dress appropriately for cold or hot weather and adjust
home temperature. Housekeeping neglect ranged from untidy and dusty to dangerously cluttered, emitting
foul odors and vermin (descriptions of extreme clutter were also coded as Hoarding). A few were unable
to care for pets, evidenced by animal skin issues, strong odors, fleas, and animal feces in the home. Denial
or limited awareness of declining ability for self-care was common. For example, one conversation
between the client and her son revealed:
[he said] she had not taken the medication ‘in a long time,’ and sates that she has not been to the
doctor in a couple years. Clt disagreed and stated that she has an upcoming doctors’ appointment,
but was unable to recall when, where, and the name of the doctor. The clt appears to be very
confused and not aware of...the decline in her own abilities (physical and cognitive impairments).
Another client had “pants...saturated in dried urine and she had what appeared to be dry fecal matter
under her toenails. The clt denied that she was as unkempt as she presented, stating that she took a bath
earlier that morning.” Some who needed help were receiving care, though additional support appeared to
be needed or the existing care was short-term. Caregiving Provided was observed in 63.6% of the sample,
which included home delivered meals, companionship, transportation, housekeeping, assistance with
errands, accompaniment to doctor appointments, grocery shopping, meal preparation, home repairs,
bathing, medication management, and task organization. Ten cases with high level of unmet needs were
considered by the FC team for Conservatorship, California’s term for adult guardianship. These were
characterized by severe impairment resulting in inability to meet basic needs and self-protect from harm.
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Health. Health Issues such as physical symptoms, diagnoses, physical impairment or
dysfunction, and use of acute medical intervention was apparent in most cases (90.9%). Health problems
varied greatly; some were ill with short-term symptoms, others had longer term patterns that became
physically disabling and detrimental to quality of life. Multiple concurrent health problems were observed
in 86.4% of the sample (n=19), with a mean of 5.2 problems (SD=2.1), and maximum of nine health
issues in one case. Ten were hospitalized in the duration of FCSA care, several exhibited end-of-life
symptomologies, and four died. Sub-themes were Physical Limitations, Pain, Injury, Hospitalization,
Falls, Illness, Diagnoses, Incontinence, Heart Attack or Stroke, Died, Difficulty Breathing, and Surgery.
More than half had Physical Limitations (54.5%), which included impaired ambulation, poor hearing, and
impaired vision. Three were reliant on wheelchairs, one became blind. Hearing loss resulted in limited
communication in three cases. Pain was experienced by half (50.0%), from sciatic pain or generalized to
specific body parts (e.g., shoulder, back, stomach). One was caused by a car accident years earlier,
another was from job-related knee injury. Some lost interest in socialization, as a result. Several were
prescribed pain medication, which one refused to take. For some, Pain was caused by Injury unrelated to
abuse, observed in 45.5% of the sample by FCSA or reported by client or caregiver. Falls were the cause
of three of the clients injured, and two clients were also abusing alcohol and pain medication. Two had
sustained Injury years prior (e.g., back, knee) and continued to need care, and one suffered brain Injury as
a child, which resulted in intellectual disability. Hospitalization occurred in 45.5% during FCSA care, and
four clients had a history of paramedic and emergency service utilization. All who were hospitalized had
multiple concurrent issues including fall-related injury, cough, shortness of breath, low blood pressure,
seizure, stroke, confusion, pain, leaking cancerous mass, diarrhea, and adverse reaction to medication.
Several experienced challenges with safe hospital discharge, and three transferred to long term care
facilities. Falls occurred in 40.9%, in clients also exhibiting unsteady gait, and refusal or lack of insight to
use assistive ambulation devices was common. Most Injury from falls were limping, epidermal bruises on
the face and extremities, and abrasion. Over a third (36.4%) experienced symptoms of illness, such as
dizziness, fatigue, loss of appetite, insomnia, weakness, or epidermal rash, and six of the eight also
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experienced Hospitalization. Diagnoses of chronic illness, such as breast cancer, diabetes, and
emphysema, were in a third of cases (31.8%). A quarter (22.7%) were Incontinent, and almost one fifth
(18.2%) had experienced a Heart Attack or Stroke. In some, multiple health issues were apparent at initial
assessment. For example, one client was:
diagnosed with Emphysema, and is able to manage her medication independently...Clt reports a
recent fall (2 weeks ago) in her bedroom, due to tripping over a cord. Clt states that she had a
bump on her head, and showed...a bruise on her right upper arm. Clt’s daughter states that they
called the doctor, and the doctor advised clt to place an ice pack on her head for swelling...Clt
presents with a thin frame, and reports losing 42 lbs within the past two years, stating “I do not
have an appetite for anything.”
Death occurred in four (18.2%): one with progressive alcoholism and frequent falls, and another reported
ongoing multiple physical complaints (e.g., weight loss, weakness, dizzy, nausea, and shortness of breath)
with many related hospitalizations prior to death, one from cancer, and another from chronic obstructive
pulmonary disease. Two had Difficulty Breathing and two had Surgery.
Preferences. Preferences regarding services, caregiving, activities, and personal desires were
expressed to the FCSA in 90.9% of cases; while not problems, preferences clarified motivation, and in
some cases were related to safety risk. Sub-codes were Decline Assistance, Consent, and Perspectives.
Declined Assistance occurred in 18 cases (81.8%), and was often alongside insistence of self-
efficacy and adequacy of existing support system. Types of services refused were varied and included
medical treatment for illness or injury, mental health services, housing assistance, foreclosure assistance,
home delivered meals, hoarding clean up, and conservatorship. Several expressed distrust of service
providers and investigators (e.g., Mental Health, physicians, APS, PG, Law Enforcement, FCSA). One
accepted an offer for introduction to mental health services, and after the introduction said “I do not need
your assistance. I am not crazy.” In discussing health care, another client told the FCSA “All the doctors
want is money, but they don’t offer you any help.” Another example was relayed to the FCSA by a
caregiver:
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The clt is ‘very upset,’ and believes that FCSA is trying to take her caregivers away. The clt has
become guarded and resistant to FCSA involvement, as well as other service providers. FCSA
was eventually able to talk to the clt to reassure her that her role is to advocate for the clt, not to
take any of her caregivers away. The clt stated that she understood, but it was evident buy her
tone of voice that she is somewhat resistant to FCSA’s involvement.
Some insisted on privacy and were reluctant or refused home entry or access to certain areas of the home
(e.g., kitchen, bedroom). Increasing decline in one client’s home condition was observed by the FCSA,
including “papers, blankets, ropes, food items, trash, etc. FCSA asked the clt to see inside the home [and
take pictures]. Initially the clt was very hesitant, stating ‘I do not want these pictures used against me.’”
Some alluded to belief that accepting help would compromise their independence or the continuance of
their relationship with a suspected abuser. Others did not refuse outright but avoided help through
repeated cancelation or postponing appointments, citing fatigue, headache, or anxiety, as reasons. In one
instance, the FCSA observes that “It continues to be a habit of [client and suspected abuser] to schedule
appointments...and then cancel them the day/morning of...at this point, my hands are tied.” In a few cases,
caregivers declined in this manner, or lacked follow-through on action steps. Service types refused by
caregivers through avoidance or repeat cancelation were cleaning, respite care, mental health support, and
medical care.
Consent to some services/supports was given in 18 (81.8%) cases, and 16 of those who declined
formal services accepted other offers. Some wanted support with time-consuming tasks such as managing
paperwork, follow-up with an unresponsive service provider, or advocacy for rights and service access.
Many clients accepted and appreciated periodic “check ins”, or were willing to entertain discussion of
services, such as agreeing to meeting with a prospective service provider, though few actually enrolled.
Client-directed assistance with abuse cessation included help averting calls from persistent scam artists,
and regaining control over income and banking. Several repeatedly discussed wanting money repaid that
was stolen, though this did not appear to be possible.
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Perspectives included opinions about the abuse, their living environment, care providers, and general
wishes, which were expressed in 18 (81.8%) of cases; the majority were unrelated to abuse. Some desired
normalcy and engagement, such as shopping, socialization, getting a job or taking classes, and romance.
For most, driving capability was a mainspring. Others sought stability of their relationships and living
situation, requesting assistance for their abuser or a co-residing family member with mental illness or
addiction. Many expressed wanting to remain in their home. Another desire was autonomy and respect for
decisions such as relationships or financial choices, and some insisted on privacy over these matters.
Some clients who were experiencing physical impairment necessitating assistive devices expressed
repulsion at appearing handicapped in public, one “became irritated, stating ‘I don’t want to look
handicap/disabled! Do you?!’” Another client intentionally neglected use of a walker to prove
ambulation capability. In some cases, desire for independence was conveyed as not wanting to burden
family or loved ones and coincided with familial tension.
Cognitive. Impaired memory and other cognitive decline were evident in 19 cases (86.4%).
Short-term memory loss was exhibited by lack of recognition of FCSA despite many contacts, or limited
recollection of prior conversations. Other signs were lost mail and paperwork, mismanaged scheduling,
forgetting names of significant relations, limited numeracy, and inability to organize tasks. All impacted
financial, medical, and legal tasks. Severe impairment was characterized by loss of orientation to location
and year, no recognition of service providers with whom they were involved for months, or inability to
recall whether they had eaten that day.
Behavioral Health. Mental health symptoms occurred in 81.8% of participants, and sub-
categories were Depression, Mental Illness, Anxiety, Substance Abuse, Combative behavior and
Hoarding. Some clients mentioned diagnoses of specific conditions, others exhibited symptoms but were
in denial or refused treatment.
Depression was the most common sub-code (45.5%) and in many, was associated with social
issues such as loss of a spouse, familial conflict, and isolation resulting from mobility or transportation
limitations. One admitted to self-medicating with prescription opioids. Another showed signs of
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depression after being placed in a nursing facility. Symptoms included excessive fatigue, crying spells,
withdrawn emotional response, or refusal of social contact. Four explicitly declared wanting to die:
The clt stated that the staff check on her once an hour but stated that she often feels lonely in her
room and is “waiting to die.” The clt expressed feeling hopeless and believes that she is “living
too long.” The clt has expressed having little interest in anything and denies the need for any
services.
In another, when asked to specify what assistance was desired responded with:
“I just want to die!” The clt continued to verbalize her desire to die, and that she felt like she was
a burden to her son, and that there was no point in her living. FCSA questioned if the clt has
made a suicide attempt or if she only idealizes suicide, clt states “I would just stop taking my
medication.”
One client “stated that he wanted to stab himself and run into traffic. The clt later minimized these
thoughts; [Medical social worker] believes it was because he did not want to receive mental health
services.”
Mental Illness symptoms were observed in 40.9% of clients (n=9), and included paranoid
delusion, hallucination, personality disorder, and illogical and disorganized reasoning, and for most
resulted in limited comprehension of consequences and self-defeating behavior. Almost all lacked insight
about their symptoms or dismissed them as normal. Challenges communicating and following through
with case plans was common. Substance Abuse of both alcohol and prescription medication was observed
in a total of five clients (22.7%), and in three clients was concurrent with Mental Illness. One visited
multiple physicians to obtain prescription opioids. Several increased substance use over the duration of
FCSA documentation and denied the problem or refused rehabilitative treatment. Some clients did not
admit Substance Abuse to FCSA, but it was revealed through accumulating observations of slurred
speech, forgetfulness, injury, empty bottles or medication containers, and concerns shared with the FCSA
by others.
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Anxiety was observed or admitted in six clients (27.3%), and four stated it was due to
environmental stress: a noisy household, debt collection, and support group participation; two were
diagnosed with Anxiety and treated with prescription medication, but still experienced symptoms.
Combative behavior, observed in five clients (22.7%), was characterized by excessive argumentativeness,
insults, and other verbal abuse, most of which were expressed toward service providers. Hoarding
occurred in the homes of five clients (18.2%), and was characterized by clutter limiting use of the home,
both inside the house and in client’s yards or vehicles. Several expressed shame regarding the condition
of their home, but one perceived it as her right and was combative when neighbors offered cleaning
assistance:
The clt had two RV’s at her home and the clt had items, trash, food, and miscellaneous items all
over her property. The clt also had “neighbors” walking in and out of her house, which the clt
states that they are assisting her with cleaning her property and helping her move. The clt became
verbally and physically aggressive towards her neighbor when the neighbor attempted to throw
items away.
Related hazards were fall risk, illness from unsanitary condition, and food poisoning. Two could not
access their bed, and one admitted to sleeping on the porch. Homes emitted foul odors and attracted
wildlife and insects.
Financial. Two distinct financial issues emerged in 72.7% of cases: Low Income (63.6%) and
need for Financial Oversight (68.2%), which were often concurrent. Low Income, classified as inability to
afford basic needs, was due to financial exploitation losses in two cases, and the remainder either suffered
long-term poverty, or had mis-managed their funds. A few habitually purchased unnecessary items,
despite threat of financial insecurity. Several requested financial supplement for housing, utilities,
medication, and food. Financial Oversight in two-thirds of the sample (68.2%) referred to apparent
inability to manage money and organize other financial tasks such as bill payment, insurance, and
property ownership; differentiated as assistance Needed (40.9%), in those who struggled to complete
financial tasks, and Provided (40.9%), in those receiving help. Six clients experienced both, and despite
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assistance, mis-management persisted because designee was unscrupulous, incapable, or unable to
provide help to the extent needed. Cases lacking oversight were characterized by unpaid bills, overdrawn
accounts, and debt collection activity. Several had pending foreclosure and did not comprehend or were
unable to address the issue. One had adequate income but did not follow through with bills and another
erroneously believed nonpayment was a bank error. Issues in Financial Oversight co-occurred with
memory lapse, impaired judgement, and mental health problems that limited client ability to follow
through with instructions and paperwork.
Health and Community Services. Issues with health care and social services were observed in
over two-thirds of clients (68.2%), despite FCSA advocacy; sub-codes were Access, Medication
Problems, Poor Quality, and Oppose Client Wishes. Access to health care was a challenge for half
(50.0%). Examples include inability to acquire durable medical equipment or social services despite
eligibility and repeated requests, two were unable to get transportation in the location and timeframe
needed, insufficient caregiving time allotment, and difficulty obtaining financial assistance for medical
procedure. Medication Problems were observed in 36.4% of cases, and included noncompliance,
overdosage, and severe side effects (e.g., hallucination, internal swelling, physical pain). Six clients
experienced Poor Quality Service, and three clients had wishes opposed by service or health care
providers.
Social. Social Isolation was present in almost a third (31.8%) of clients. Factors that reduced
access and interest in social connectivity were chronic pain, physical impairment, and inability to drive.
Some were estranged from family, related to client mental illness and behavioral unpredictability. Five
client phones were either disconnected, or not answered by person or answering machine after many
attempts. Social Support was also observed in one third of the sample (31.8%),
Safety. Risk unrelated to abuse presented in more than half of the cases (59.1%), which was often
contested or not comprehended by the client. Danger of fall-related physical injury was sometimes a
result of medication, substance abuse, and home clutter or disrepair. Two were at risk of vehicular
collision in public streets, one for unsafely walking into the road and another for driving a golf cart.
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Another became homeless, slept in an alleyway and possessed a gun. Some risk was not directed at the
client but was disruptive to care provision and potentially psychologically damaging, such as conflict
among family and caregiver and disagreement on client care.
Housing. Half (50.0%) experienced issues related to or compromising housing; three sub-themes
were Housing Issues, Facility Placement, and Neighbor Conflict. Housing Issues (40.9%) included risk of
or finalized foreclosure; four were impaired and lacked the ability or the insight to prevent the loss, two
had severe mental illness symptoms (e.g., paranoia, delusion) but were undiagnosed and declined mental
health services. One became homeless and refused housing support but did not qualify for
conservatorship because, despite paranoid delusions, the client presented as capable when assessed by
professionals and refused behavioral health treatment. Neighbor Conflict such as exchanges of shouting
and aggression with neighbors occurred in four clients (18.2%). Initiation was by the client in two
situations, one was mentally ill, and neighbor was observed damaging the client’s property. Facility
Placement was discussed or occurred for eight clients (36.4%); three who were placed had severe
cognitive impairment, two were dependent adults who relocated to board and care facilities, and one
cognitively intact but quadriplegic adult was unable to safely return home after cancer complications.
Transportation. Inability to drive, unsafe vehicle operation, and challenges with vehicle
maintenance were observed in half of cases (50.5%), and most were due to visual or cognitive impairment
or medication side effects. Some with driving capability required help with aspects of vehicle ownership
such as communication with mechanics, addressing traffic violations, or fulfilling DMV requirements.
Those who were losing or had recently lost ability to drive were concerned about reduced socialization.
Caregiver. Caregiver Tension occurred in 10 cases (45.5%), between the client and caregiving
family members, friends, or acquaintances. Some caregivers were tasked to provide help in exchange for
housing but struggled with the responsibility due to mental health and substance abuse. Most had been
involved with the client for multiple years. Exhibition of tension ranged from exchanges of verbal
aggression between the caregiver and client, caregiver interruption or infantilization of the older adult, or
client resentment of caregiver intrusions. Some shared fearful concern for the caregiver’s wellbeing.
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Several were conflicted with both needing yet resenting care. Caregivers admitted to struggling to provide
needed care, were verbally abused, overwhelmed, and several were tasked with mitigating client abusive
behavior toward service providers. Caregiver Impairment was observed by the FCSA in two caregivers
suspected of abuse, including mental illness or substance abuse, who requested various forms of
assistance from the FCSA.
Abuse. One fifth (18.2%) experienced Abuse History prior to the circumstances precipitating the
FCSA intervention. For one participant, abuse history was the same type of scam victimization, by
different abusers. Two were from much earlier in life, such as child molestation and domestic violence.
Two described having learned from the experience. Those who exhibited concurrent substance abuse or
mental illness symptoms denied experiencing negative effects, and none received trauma-informed
psychological treatment for the prior abuse. Current Abuse and exploitation risk were active for seven
clients (31.8%), such as continued loss of money to family or fraudulent schemes and scam artists,
caregiver neglect or withholding medication, and verbal threats. The majority of these incidents were not
witnessed firsthand but relayed by the client or another observer to the FCSA. Five clients experienced
New Allegations in the duration of FCSA involvement.
DISCUSSION
EM is broadly known for complexity, yet there is no objective examination of the precise issues
or the nature of their interaction. Applying content analysis to detailed narrative case notes of a FCSA
assisting difficult EM, multiple themes were identified: Caregiving, Health, Preferences, Cognitive,
Behavioral Health, Financial, Health and Community Services, Social, Safety, Housing, Transportation,
Caregiver, and Abuse. Within the themes, 44 distinct codes were identified. Each case revealed multiple
complex challenges, many appeared to have originated years or decades prior to the EM that catalyzed FC
involvement, though exact duration was difficult to quantify because sufficient detail was not confirmed
but inferred by the FCSA. In all cases, the problems were interconnected, and often mutually
exacerbating. Some revealed long-term history of abuse, which may have been underreported in this data
because most had symptoms of emotional trauma, such as substance abuse, emotional dependency,
Rowan Dissertation – Fall 2019 50

mental illness, and hoarding (Hamby et al., 2016; Kehoe & Egan, 2019). Many cases exhibited EM risk
factors, such as poor mental health, substance abuse, cognitive impairment, low income, functional
dependence and disability (Pillemer et al., 2016), this research is the first to describe multiple, interrelated
issues outside of the abuse that created significant challenges resolving the abuse. The range of problems
identified, and volume of concurrent issues demonstrates the challenges resolving highly complex cases
of EM.
Refusal of help in extreme examples described in this chapter may appear, from an outside
perspective, as indicative of cognitive impairment. However, they were also alongside requests for
respect, freedom to choose, privacy, and stability in home and relationships. Assistance desired were, in
most cases, conducive to client control over their circumstances, such as help regaining financial control
from an abuser, advocacy for health care services, and assistance with creditors. In some cases, refusal of
help was not a sign of impairment but motivated by desire to preserve of individual control and dignity,
and a reasoned choice to maintain personal independence. The literature supporting person-centered
philosophy provides strong evidence that removal of choice is detrimental to emotional and physical
wellbeing (Mallers et al., 2014). Services and assistance declined appeared to be due to remedial nature of
services. Some were offended at implication of lost physical or cognitive capacity. Others feared
accepting help would result in loss of important relationships and living status, a common theme in the
scarce literature on victim perspectives. Services accepted were those that offered empowerment through
advocacy or facilitated independence. Personal perspectives revealed the importance of sense of
normalcy, which included socialization and freedom of choices.
The constellation of needs evidenced in these cases, such as fall prevention, end-of-life care,
polypharmacy, social isolation, transportation transitions, and caregiving, are not new to aging services.
Prescription of an array of interventions is a natural response. However, given that need for assistance
was just as common as refusal of assistance warrants a closer look at perceptions of presentation of social
supportive services for older and dependent adults, and to what degree they undermine self-efficacy and
personal identity. Examination of complex cases as these through the lens of abuse risk and intervention
Rowan Dissertation – Fall 2019 51

may inhibit examination of reasoned choices made by the victim, in which problematic situations may
have been arranged to meet other needs. Without a full understanding of the contextual factors (e.g.,
economic status, long-term trauma) and the mutuality with social relationships, any success in reduced
risk may not be sustained.
These findings are a sub-set of the most complex cases in a large urban county. Complexity
revealed many themes with a relatively small sample. Themes identified provide a rich starting point for
operationalizing and measuring EM complexity. Many findings reflect existing EM literature, and
concurrent issues faced by EM victims. Further work is needed to incorporate victim perspectives into
supportive service design. Community Based Participatory Research may be a viable approach to assess
current services and supports for older and dependent adults. If services are not presented in an acceptable
way that ensures the personal sense of value and empowerment in the recipient, it may leave many
vulnerable to the effects of neglected care, isolation, and mistreatment by unscrupulous individuals who
provided the social connectivity they desire.
CONCLUSION
While identification of and addressing risk is a key focus of addressing EM, this research shows
that in the most complex cases, risk alleviation cannot be adequately accomplished in isolation from the
other aspects of the persons’ life. Of these, identity preservation may be a driving motivator for both
declining or accepting assistance. The nature of challenges in this sample suggest impairment and refusal
of help exacerbate isolation and vulnerability. Although therapeutic, trauma-informed care with a focus
on client strengths may be an effective approach, it is imperative to invite older people who receive
services to be equal participants in service and evaluation design.

Rowan Dissertation – Fall 2019 52

CHAPTER IV
TOWARD NATIONWIDE REPLICATION OF ELDER MISTREATMENT
MULTIDISCIPLINARY TEAMS

INTRODUCTION
Multidisciplinary Teams (MDTs) are recognized as an important approach to comprehensively
address complex elder mistreatment by creating forums for cross-agency communication and learning,
access to technical expertise, and aiding identification of service gaps or overlap (Wigglesworth et al.,
2006; Navarro et al., 2010). Research is scarce but encouraging, with evidenced efficacy in risk reduction,
protective intervention, and criminal prosecution (Navarro et al., 2012; Gassoumis et al., 2015; Rizzo et
al., 2015). Anecdotally, those who have experienced EM MDTs intuit the powerful synergy of teamwork
(Breckman et al., 2015). Considering the lack of EM intervention research overall, MDTs are highly
promising (Pillimer et al., 2016), and prioritized for replication in the Elder Justice Act (EJA, 2010). At
the same time, there has been no research on the role of MDTs in directly improving the lives of the
victims whose cases are reviewed (Fearing et al., 2017).
While empirical evidence focuses on resource-rich MDTs, the body of descriptive literature
indicates wide definitional variation, ranging from an ad-hoc meeting of a social worker and a nurse
(Ernst et al., 2012) to structured weekly meetings of diverse professionals (Anetzberger, 2011; Teaster et
al., 2003). Barriers to effective teamwork range from procedures and protocols to personalities
(Anetzberger, 2011). Given informational deficits, and the effort of strategic replication, experts agree
that a nationwide descriptive scan is imperative (Breckman et al, 2015). Teaster and colleagues 2003
survey of EM MDTs is a helpful foundation, and the growth of the past fifteen-years must be explored to
provide a scope of the current state of MDT structure, activities, and definitions of success.
To approach nationwide replication of EM MDTs strategically, it will be important to identify
successes and challenges of those developing and sustaining teams, drawing from the experiences from
communities varied in economic resources and population density. To develop a coherent strategy for
systematic change, Lewin’s field theory (1951) is a tool to identify variables that can be adjusted for the
greatest possible gains. Field theory postulates that systemic stability is a dynamic state of equal pressures
Rowan Dissertation – Fall 2019 53

from opposing direction: driving and restraining forces. Change occurs from loss of equilibrium due to
increased or decreased force of drivers and restrainers, such as infrastructure, politics, and belief systems
(figure 4.1). By identifying and assessing the malleability and potential impact of all forces for and
against, change initiatives can plan targeted adjustment toward the greatest gain (Lewin, 1958). The
purpose of this paper is to present a comprehensive representation of environmental drivers and resistors
toward the replication of EM MDT’s, and to aid evaluation efforts by cataloging indicators of success.
The aim is to inform policymakers by presenting a national scope of policy and infrastructural
adjustments most conducive to systematically bolster the EM response system, with a consensus of
research questions for future study of MDT structure, process and outcomes. Research questions are (1)
What are the barriers and facilitators of MDTs? And (2) What is success?

Figure 4.1 Lewin's Force Field Analysis Model
METHODS
Because qualitative consensus methodology is an optimal approach for examination of
phenomena in which quantitative data are not obtainable yet there are experts with extensive first-hand
experience (Fink, Kosecoff, Chassin, & Brook, 1984), we elicit advice from a range of experts with
experiential knowledge working in, developing, and running EM MDTs.
Project Components
This study consisted of several components. First, a narrative literature review was conducted by
the first and second authors to scan for experimental and descriptive research on EM MDT’s. A summary
Rowan Dissertation – Fall 2019 54

of the literature was iteratively revised by a team of five researchers with expertise in Gerontology,
Geriatrics, Psychology, and Policy, all of whom had extensive involvement developing, facilitating,
participating on, and/or studying EM MDTs. From this process, two framing questions were chosen to
elicit responses on priorities in MDT replication and research: “What are the barriers and drivers of
MDTs?” and “What outcomes indicate MDT success?”
The second component was an Expert Panel of 12 participants, selected by the 5-member
research team based on prominent leadership in the field of elder justice and MDTs, with a broad range of
disciplinary expertise, including victim services, psychology, geriatric medicine, law enforcement, elder
abuse prosecution, social services, legal analysis, and research (appendix 1). The panel was convened for
two consecutive days in March 2017 in Pasadena, California and was provided in advance with a written
summary of the literature review and discussion questions. The convening began with presentation of the
review, including unpublished and preliminary findings of research in progress, to inform expert panelists
on current knowledge on EM MDTs. Majority of the time was allocated for conversation and debate
among panelists, facilitated by the team of researchers, three of whom took comprehensive notes.
The third component was a nationally distributed survey inquiring about EM MDTs, to inventory
existing MDT structure, activities, outcomes, and challenges. Design was led by the second author of this
paper, developed through weekly consultation by the research team, with advice and review by the expert
panel at the convening. The survey was distributed electronically from May 30 to July 01, 2017 through
aging service and advocacy networks via email listservs. For states with no response after three waves of
solicitation, calls were placed to Area Agencies on Aging and Adult Protective Services inquiring about
known MDTs and if any were identified, requesting response.
Data
Detailed notes of expert panel discussion were taken by three researchers and integrated into a
single document, reviewed and agreed to be representative of panel content and discussion by. Survey
data were open-ended responses to two questions: “What are the barriers of this MDT?” and “Share any
Rowan Dissertation – Fall 2019 55

comments, questions, etc.” Quantitative findings on MDT structure, activities, outcomes are presented
elsewhere (names, in progress).
Analytic Strategy
Analysis was conducted in NVivo Pro 12, with multiple iterative steps to validate and refine
interpretation (figure 1). Thematic analysis was initially applied to deductively identify barriers,
facilitators, and outcomes, followed by inductive content analysis within the framing questions. This
strategy allowed examination of types and trends of specific content addressing the research questions.
Content codes were grouped into broad themes, which informed a preliminary model. This model was
presented to the research team for feedback, then separately to three members of the expert panel, one
representing legal policy, another social service delivery and program development, and the third federal
government MDT technical assistance. Data coding and definitions were next reviewed by the second
author to validate and revise findings.

Figure 4.2 Analytic Strategy
RESULTS
The majority of survey respondent (n=324) primary role on MDTs were team members (n=189,
58.0%), a third were the facilitator or coordinator (n=103, 31.6%), a fifth were presenters (n=61, 18.7%),
and the rest were observers (n=46, 14.1%). Half had 11 or more years of experience working with EM
issues (n=148, 48.8%), a fifth had 6 to 10 years (n=68, 22.4%), a fifth 2 to 5 (n=68, 22.4%), and 6.2% had
Rowan Dissertation – Fall 2019 56

less than a year experience (n=19). The majority were frequent (n=234, 71.3%) or occasional (n=57,
17.4%) attendees of an EM MDT, and most had attended within the past year (n=270, 82.3%). Agency
affiliation of respondents were over a third APS (n=110, 36.3%), followed by other unspecified
governmental agencies (n=48, 15.8%), non-APS social services (n=33, 10.9%), district attorney (n=20,
6.6%), legal services (n=20, 6.6%), healthcare (n=15, 5.0%), law enforcement (n=7, 2.3%), family
violence services (n=6, 2.0%), and financial institutions (n=4, 1.3%); 13.2% of respondents did not
specify (n=40). Most expert panel members (n=12) had greater than 11 years of experience (n=10,
83.3%), and the remainder had 6 to 10 years (n=2, 16.7%); all contributed to discussions on which
detailed notes were taken and included for analysis.
Survey respondents were asked to select up to three perceived barriers to the success of MDTs.
The most prevalent were lack of member engagement (51.0%), funding and resources (37.4%), time
commitment (34.6%), agency commitment (24.1%), difficulty identifying cases for review (14.9%), and
inability to share information (14.9%). One-fifth (19.2%) did not believe there were any major barriers.
Respondents were asked to provide specification on “Other” types of barriers as free-response text,
producing 37 qualitative entries. and 238 respondents offered up to three qualitative suggestions and
comments.
The broad content categories were: Barriers, referring to challenges of team start-up, operation,
sustainability, and evaluation; Making Teams Work, which in some cases was indistinct from Barriers by
implication of unsupplied needs, and additionally included questions and innovative solutions; Measuring
Success described indicators of team sustainability and positive impact, and included discussion of
hypotheses and research methodology. Though only one survey question explicitly asked for challenges
with MDTs, barriers were described in responses for questions and comments. Survey respondents
provided more content proportionate to total code references than expert panelists on Making Teams Work
(20% Survey; 9% Expert Panel), and fewer on Measuring Success (7% Survey; 21% Expert Panel); the
majority of the discussion on Barriers by the panel was focused on methodological challenges of
Measuring Success. Four cross-cutting groups of codes were identified, representing core components of
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MDTs: Resources were monetary and non-monetary support (e.g., stakeholders, time commitment,
leadership); Membership referred to the selection, engagement, and participation of professionals; Case
Review focused on cases brought to the team including in-meeting discussion and follow-up assistance,
and Client described case subject characteristics and circumstances. Survey respondents and expert
panelists described similar barriers, and while 11 survey respondents submitted innovative ideas, the
majority of specific solutions and resources addressing Barriers were from expert panel data.
Barriers and Facilitators of Making Teams Work
Resources. Most frequent barriers identified quantitatively were funding/resources and time
commitment, and qualitative data provided further context. Sub-themes identified through content
analysis were Public Awareness, Funding, Leadership, Sustainability, Stakeholders, Time Commitment,
and Direct Services (table 4.1).
The most frequently mentioned barriers perceived to hamper team start up were Public
Awareness, a theme that only emerged from survey data, followed by lack of Funding, mentioned by both
survey respondents and expert panelists. Broad recognition of EM as a problem was seen as necessary to
garner interest among stakeholders. Both survey respondents and expert panelists noted a paid coordinator
was important for achieving team Sustainability by enhancing communication within and outside
meetings, maintaining stakeholder commitments, and arranging for member training. A professional team
coordinator was believed to be instrumental in nurturing team cohesiveness and continually developing
and strengthening relationships among members and agencies. Time Commitment was a challenge for
those with high caseloads or broad scope of responsibility. Rural communities face distinct challenges of
large geographic regions, more limited resources, and lack of EM specialization, according to EP and
survey respondents. Ineffective Leadership and mismanagement of meeting time was felt to drive down
attendance, a sentiment noted only in survey data.
Two survey respondents were interested in strategies for Sustainability with minimal resources,
and another suggested exploration of non-traditional funding streams, but there were no concrete
suggestions or examples of teams that had achieved satisfactory operation with little Funding. Both
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survey respondents and expert panelists explored ideas about partnerships with private organizations such
as hospitals and banks; one survey response described the potential as a source for monetary or in-kind
resources such as expert consultants or meeting space, though protocol for establishing mutually
beneficial arrangement with protection from conflict of interest are needed. One expert panelist noted that
knowledge of systemic money allotment from public funding and grants could identify duplication across
agencies toward potential partnerships to pool money toward shared goals, with greater leveraging of both
human and material resources. Technological resources, such as tele- or video conferencing, were
suggested to alleviate time and geographic challenges, although one survey respondent described
technology as a Barrier due to poor sound quality inhibiting effective use. Another survey response noted
that cross-agency data systems could improve case follow-up between meetings, and may reduce need for
paid staff. Leadership was noted in surveys and expert panel discussion as a key driver of team startup,
and aiding sustainability by crafting a team mission beneficial to all partners. One survey respondent
suggested that Leadership across regions would be helpful, such as a steering committee to “advance this
intervention nationally, including focusing on MDT research, scaling, [and] sustainability.” Four expert
panelists affirmed that more funding is currently available for EM MDTs than in decades prior, and
several advised on creative strategies for obtaining resources (e.g., framing MDT objectives to fit funding
aimed at broader populations, potential for pooling resources to fund a dedicated MDT facilitator).
MDT Membership. Membership was the most frequently discussed element of MDTs across
data sources. The proportion of code references between data sources was comparable (23% survey
respondents; 21% panelists), and the majority of content described professional expertise needed on
teams, and relational aspects of membership. Sub-themes were Agencies and Disciplines, Recruitment,
Engagement, Training, Tension, and Collaboration.
Survey respondent comments on membership listed specific members perceived as essential to
team operation, yet challenging to engage and retain. Overwhelmingly, law enforcement was the most
frequently cited (n=28), followed by medical professionals (n=11), and EM prosecutors (n=10), with
requests for advice on engaging these groups. Other types of members noted as essential, but lacking were
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behavioral health practitioners, banks, forensic accountants, community-based service organizations, and
professionals to conduct capacity evaluations. Recruitment and Engagement barriers were described as
poor attendance, lack of interest, and limited coordination among members; these challenges were
believed to be exacerbated by staff turnover, mentioned in both survey responses and in expert panel
discussion. Tension between team members due to conflicting ideology or perceived ineffectiveness,
specifically among law enforcement, APS and judges, was described in survey data. Cross-agency politics
were said to hamper team effectiveness. Tension was attributed to challenges with Collaboration in
meetings.
Diversity among Agencies and Disciplines was important, though some disciplines were noted as
drivers of team efficacy: law enforcement, medical professionals, mental health, and financial experts.
Expert panelists engaged in robust discussions about effective strategy and policy in team member
engagement, including the importance of team-building and surmising that engagement might be fostered
in members who were initially reluctant to participate in team discussions. One survey respondent
suggested “term limits” or enlisting multiple individuals from an agency could integrate alternate
perspectives within single agencies, and three others suggested that team member desire to participate
was necessary to be a useful contributor. Targeted and ongoing Recruitment and Engagement of agencies
and individuals was perceived as essential by both panelists and survey respondents, such as nurturing
consistent attendance and cross-agency communication. Training was mentioned in both data sources,
with specific suggestions by expert panelists on providing members with cross-agency knowledge,
agency-specific strategies for effective communication within the MDT, and activities engendering
camaraderie among team members. Both structured training and in-team observation and experiential
learning were described as important (e.g., communication techniques, information-sharing), and it was
noted that effective content and approaches, even those occurring by happenstance, should be recognized
and shared for intentional replication in other teams. Expert panelists also described the importance of
succession planning for member turnover, and noted the specific communication and listening skills
required for successful team development and facilitation.
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*Percentage of total coded reference within the coded group **Other barriers ***Comments/Questions
+
Expert Panel

Case Review. Case Review discussion is the focal activity of EM MDTs (Navarro et al., 2010),
but was not mentioned as frequently as Membership or Resources. Sub-themes were Presentation,
Confidentiality, Selection, Disagreement, and Follow-up.
The most frequently noted issue among survey responses was Confidentiality, that differing
protocols across agencies resulted in inability to share information, preventing effective presentation and
collaboration, especially when multiple partners were involved with the client. Disagreement among team
members was inability to develop consensus on definition of abuse, criteria for intervention, and client
capacity to self-protect and self-care. Some felt these challenges stemmed from misunderstandings about
other agency’s role and capacity; three respondents inquired about how to manage majority consensus on
Table 4.1. Barriers and Facilitators Sub-Themes
Sub-Theme B**C***EP + Definition
Resources 10 144 5
Public Awareness 47 (20.7%) 3 44 0 Awareness of EM as a public problem among public and stakeholders
Funding 38 (16.7%) 1 35 2 Monetary support for staff and infrastructure
Time Committment 23 (10.1%) 5 18 0 Time investment by stakeholders and team participants
Leadership 18 (7.9%) 0 17 1 Leadership of meeting facilitation, team vision, and member
Stakeholders 12 (5.3%) 0 12 0 Organizations potentially benefitting or participating on
Sustainability 11 (4.8%) 0 9 2 Continued operation and stakeholder interest
Direct Services 10 (4.4%) 1 9 0 Services for abuse victims
Membership 16 209 20
Agencies/Disciplines 88 (23.5%) 7 78 3 Agencies and disciplinary expertise on MDTs
Engagement 73 (19.5%) 1 64 8 Meeting attendance, participation in case discussions, enthusiasm
Training 29 (7.7%) 2 21 6 Cross-disciplinary education, MDT process and participation, or general
EM
Collaboration 23 (6.1%) 0 21 2 Teamwork and relationships
Tension 20 (5.3%) 6 14 0 Disagreement, misunderstanding, or resentment
Recruitment 12 (3.2%) 0 11 1 Member selection and commitment to participate
Case Review 8 77 9
Confidentiality 23 (15.2%) 2 20 1 Confidentiality and information-sharing between members
Follow-up 23 (15.2%) 0 22 1 Case assistance and collaboration commitment after case presentation
Presentation 22 (14.6%) 3 17 2 Case description organization, content, and effectiveness
Selection 19 (12.6%) 1 13 5 Decisions on cases presented to team, including reasons for not
presenting
Disagreement 7 (4.6%) 2 5 0 Disagreement among team members on case circumstances or action
Client 1 24 9
Capacity 14 (27.5%) 0 11 3 Cognitive and physical ability to self-care or self-protect
Outcomes 14 (27.5%) 0 9 5 Outcomes and measurement approaches
Preferences 6 (11.8%) 1 4 1 Trauma, viewpoint, and wishes
n (%)*
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needed action that was contrary or outside the case presenter’s role. Related to this, case plan Follow-up
assistance from the team was described as inadequate, specifically noted as a challenge when team
decisions required direct assistance with complex, technical recommendations, yet none was provided.
Another common topic in Case Review observed in survey and expert panel data was case
Presentation. Survey respondents expressed frustration from pressure placed on case presenters;
diametrical to this were desires for case presentations that were more effective, noting poor organization
of information, lack of clearly stated purpose, and adequate information or documentation to address
presenter goals. Case presenters noted experiencing criticism of their agency, their work with the client,
and presentation to the team, resulting in reluctance to bring cases. Selection of cases included concerns
over scarcity, and some described that urgent cases warranting immediate attention, were not suitable for
MDTs with infrequent meetings. Expert panelists surmised that case scarcity was a result of presenter
discomfort with power differential, high expectations, and brash communication from team members.
However, solutions for each of these issues were described by both survey respondents and expert
panelists, with the majority contributed by the later. One expert panelist urged that Presentation can be
helpful at any stage of work with EM victims. For example, MDT consultation early in the investigation
could result in more efficient and thorough assessment and case plan development, equipped with advice
and direct assistance from the team. Several panelists noted that case presentation with clearly defined
objectives and questions for the team, accompanied with team training on supportive communication,
would ease Presentation challenges. Several expert panelists were developing manuals for MDT
operation with recommendations that teams determine objective case Selection criteria, as well as a
structured format for case presentation and discussion, which were observed to improve discussion
efficiency in some teams. Both expert panelists and survey respondents noted the benefits of successful
case Presentation. Follow-up by team members after case review, such as assistance on recommendations
outside the technical expertise of the presenter, was said to facilitate cross-agency collaboration and
shared case plan, which reduced burden on case presenters. In addition to advice and assistance, some
observed Presentation resulted in emotional support for presenters, validating their work with the client
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and lessoning compassion fatigue in difficult cases. Toward managing Confidentiality challenges, the
value of confidentiality agreements was noted, and some states have laws information-sharing among
trained members of MDTs. Specifically, one expert panelist described a state law that allows discussion
of confidential information on cases of elder and dependent adult abuse, when done among trained
experts in a multidisciplinary team meeting (California Elder Abuse and Dependent Adult Civil
Protection Act of 1991). Another panelist noted having developed a template confidentiality agreement
for EM MDTs (Jackson, S., 2016). Also, expert panelists noted the potential benefit of developing
infrastructure and procedure for scheduling ad-hoc meetings, through utilization of web-based video
conferencing, to alleviate geographical and time constraints.
Client. While clients (EM victims) are an element of Case Review, Client emerged as a distinct
theme because the content focused exclusively on aspects of the EM case, outside the context of team
discussion and other activities. While not a barrier to the function of EM MDTs, it was notable as a
reflection of the difficult decisions and need for resources in EM cases, underscoring the need for MDTs.
The distinction from Case Review was emphasized by the emergent sub-themes, which were Capacity,
Preferences, and Outcomes.
Challenges supporting the Client were noted by 11 survey respondents, particularly those with
impaired Capacity to self-protect, such as cognitive impairment, mental illness, and unsafe or aggressive
behavior. Respondents requested resources for capacity screenings and methods for expediting assistance
for older adults unable to manage their affairs and without informal help. Preferences were noted as
difficult to honor in clients appearing to lack Capacity, yet three respondents acknowledged the necessity
of incorporating client wishes for developing feasible case plans. Survey respondents suggested interview
techniques with client and family, such as separating family and older adult for interviews for more
accurate assessment of familial dynamics and influence over client, noting the need for capacity
assessments in the field, community support, and monitoring beyond APS’s short-term assistance for
those with cognitive decline.
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These findings support a model of restrainers and drivers to the development of EM MDTs,
depicted in figure 4.3, in which barriers restraining MDTs are opposite corresponding drivers. Some
drivers are existing resources, such as facilitation guides, coaching service for young MDTs, and
confidentiality agreement templates which have not yet been adopted by those citing the issues. However,
a major persisting barrier continues to be lack of funding for skilled team leadership and facilitation.
These findings describe anecdotal successes in acquiring funding, and strategic suggestions for pooling
funds with logical arguments for the case of shared benefit of MDTs. A major restrainer to the availability
of funds was noted to be limited convincing evidence of the value of MDTs, for which a coherent
evaluation strategy and agreement on outcome measurement may support.

Figure 4.3 MDT Force Field Analysis
Measuring Success
Evaluative questions and hypotheses were posed within each of the MDT broad themes
(Resources, Membership, Case Review, and Client), and Society emerged as an additional theme of
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success. Expert panel discussion on outcomes and evaluation research comprised a larger proportion of
total coded references compared to survey respondent data (7% survey respondent; 21% expert panel), as
this was a specific question posed to the panel. However, though not directly asked about evaluation, 98
survey respondents contributed process and evaluative questions.
Success was perceived in multiple dimensions, indicating that all stages of development
comprised potential success: resource sustainability, team composition and cohesion, productive case
processes, and outcome efficacy (table 4.2). Like Barriers and Making Teams Work, most frequent cross-
cutting theme among both expert panel and survey respondents was successful Membership and Team
Cohesion, with observations about perceived benefits. Hypotheses and questions about success were often
not mutually exclusive to one theme; success in each theme was surmised to bolster the next (e.g.,
resource sustainability and leadership would lead to strong member networks, bolstering comprehensive
case planning) and larger team impact was believed to contribute to viability of dedicated resources and
community commitment. Questions on process, hypotheses, and evaluation methodology are summarized
in table 4.3.
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Resource Sustainability. Indicators of successful resource acquisition were long-term
Sustainability and recognition of team value among Stakeholders, such as participants, and the
community at large. A causal pathway between outcomes and dedicated funding for a team coordinator
and infrastructure has not been proven, but many survey respondents and expert panelists believed teams
needed dedicated staff to be effective. However, questions were raised by survey respondents about the
Table 4.2. Measuring Success of MDTs
Theme Sub-Theme Success Indicators
Funding • Sustained funding
Stakeholders • Stakeholders invested
Training • Nurturing tomorrow’s leaders (e.g., students, incomping professionals)
Direct Services • MDT saves community resources (e.g., duplication, timliness)
Engagement • Law enforcement, prosecutors, APS, and LTCO are involved
• Medical, psychology, financial, and other needed experts attend regularly
• Members assist case presenter
• Members are enthusiastic
Relationships • Sense of comradery, shared mission
• Effective communication, trust, accountability, transparency
• Members have diverse resource network, benefitting their everyday practice
• Improved collaboration among agencies (not just among individuals at meetings)
Training • Cross-agency awareness
• Knowledge of other agency roles and service criteria
• More effective at doing their job
Presentation • Appropriate case selection, consistent volume
• Case discussion facilitates information sharing
• Improved problem-solving with complex cases
Follow-up • Case presenter gets advice that would be difficult or impossible to obtain
elsewhere
• Members contribute to case plan outside meeting
• Case presenter recieves assistance on tasks outside their area of expertise
• Reduce case presenter burnout
Outputs • Increased prosecution
• Repeat abuse is reported more quickly, improved monitoring
• Recurrence prevented
• Better screening of high-risk individuals
• Appropriate supports/services/advocacy in place
• Expedited or more complete case resolution
Client Outcomes • Abuse is stopped or addressed more quickly; long-term stability
• Improved outcomes, holistic (risk reduction, health/medical, well-being,
vulnerability, financial, social support)
Preferences • Victim preferences incorporated in case plan; empowerment; story-sharing
• Respect and honor for client
Society • Community-wide gap identification and reduction; Reduced duplication of
services; comprehensive service delivery; Cross-agency cohesion; bridge silos
• Experienced teams coach and provide technical assistance to newer teams
• Reduce victim dependency or reliance on public programs, reduced high-service
utilization (hospitalization, APS)
• System change and culture change through relationships and shared values
• Resources, re-fueling society-wide response to EM
Resources
MDT
Membership
and Team
Cohesion
Case Review
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viability of sustaining MDTs with minimal funding, and the need for adaptation of MDT models for
regions with small populations dispersed over large geographic areas.
MDT Membership Networks. Engagement of Agencies and Disciplines was noted as success, of
both the organization and individual attendee participation. One survey respondent described the
importance of expert consultants: “forensic accountants and neuropsychiatrists greatly enhance the
effectiveness of the teams.” Involvement of certain Agencies and Disciplines, such as prosecutors and
physicians, was believed by survey respondents and expert panelists to motivate interest and attendance
of other members, leading to greater team efficacy; commitment of highly valued professionals signified
success. Measuring the extent of individual engagement was described on multiple levels: attendance,
participation in discussion, enthusiasm, and follow up between meetings. It was surmised that
engagement could be fostered over time; for example, regular attendance may lead to rapport with other
members, thereby improving collaboration, all of which could be bolstered with training or team-building
activities.
Another indicator of successful member collaboration was cross-agency knowledge,
demonstrated in other research (DeLiema, Navarro, Moss & Wilber, 2016), described here on multiple
levels: first, awareness of which member could provide specific guidance; next is internalization of cross-
agency knowledge; final level was systemic learning diffused to the members’ entire agency. As such,
team membership is surmised to have the potential to benefit not just the attendees, but the entire
organizations, thereby reducing siloed systems. One expert panelist described:
There is a professional development that heightens not just the meeting work, but the
professionals in their day-to-day work have enhanced training. Their agencies, and perhaps the
entire community, benefit from added expertise and connection [to] the solutions outside the
disciplinary or agency scope.
Evaluative questions posed ranged from strategies for optimizing member engagement, to
association of causality of member engagement and cross-agency knowledge to overall team efficacy.
Case Review Outputs. Consistent and appropriate case Selection with effective management of
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Confidentiality and Tension was thought to lead to fruitful case Presentation, with benefits anecdotally
observed in multiple domains. One survey respondent noted that “having all concerned parties at the table
provides for better problem solving, reduces splitting, develops a unified client care plan and increases
accountability and transparency.” Focally, the case presenter benefits from support from the team, both by
providing access to information or assistance that would otherwise be time consuming or impossible to
obtain, and emotional support possibly mitigating burn-out and reducing human resource strain on public
agencies. A peripheral outcome of successful Case Review was member Training through information
sharing and discussion, on both content (knowledge related to EM) and experiential (how to
collaboratively participate). Member Follow-up after case discussion was surmised to contribute to
expedited or more complete outputs such as capacity or risk screening, prosecution, and enrollment in
appropriate supports, services, and advocacy. These outputs were posited to prevent or promote earlier
intervention of repeat abuse, reduce APS recurrence, and improve Client Outcomes. Case plan
acceptability to the client (e.g., incorporation of Client Preferences) was believed to contribute to
successful Follow-up.
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Client Outcomes. Client Outcomes, hypothetically improved by team Case Review, were
conceptualized holistically by both expert panel and survey respondents, the most frequently cited were
risk and abuse reduction, but also included improved health, well-being, social support, financial
independence, and long-term stability. The importance of Client Perspectives in developing Outcome
definition was acknowledged, and EM victim empowerment and feeling respected was described by
survey respondents as potential measures of success. One respondent suggested that healing might be
facilitated through victim story-sharing with the community or other victims, additionally means to
increase public awareness and reach other victims. However, focus on empowerment and person-centered
approaches in impaired victims was noted as especially difficult for law enforcement to honor. Also,
expert panelists mentioned methodological difficulty measuring successful prevention.
Societal Impact. Benefits to the larger community were conceptualized as service system
efficiency, reduced cost to public programs, and broader cultural change, all of which could improve
resource availability for MDTs. A highly functioning MDT with diverse partners participating in case
Table 4.3. Process and Evaluative Questions
Theme Sub-Theme Questions
Funding • How to sustain MDTs with minimal funding?
Stakeholders • How do you get stakeholders invested in an MDT?
Training • How do you find training for MDT meetings?
Engagement • Can mandated attendance lead to engaged, collaborative members?
• What training improves engagement of reluctant members? How to best nurture
member engagement, by discipline?
Relationships • Do improved relationships result in improved collaboration and
Training • What approach and content of training are most helpful toward member
professional development?
Presentation • What information in case discussion improves collaboration?
• What guidelines support case presenter? Streamline case discussion? Address
disagreement among team members?
• What presentation techniques lead to improved member engagement and
reduce case presenter burnout?
Follow-up • Does the inclusion of specialists improve quality of casework? Which specialists
are most important toward which types of cases?
Outputs • Does team collaboration and follow up outside meeting improve client outcomes
(e.g., prevent abuse or re-referral)?
Outcomes • Does MDT casework improve client outcomes?
• Does client story-sharing and empowerment aid in reducing abuse trauma? Is
peer-support a successful approach to improving Outcomes?
• How to measure prevention of abuse, hospitalization, or dependency?
Preferences • What outcomes do clients desire? How to include preferences of impaired
Resources
MDT
Membership
Casework
Client
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discussion was observed to provide training for leaders of tomorrow with “substantive and process skills,”
spoken by one expert panelist, and to identify and reduce gaps in service provision. Similarly, panelists
discussed that duplication in services may be reduced through member awareness of similar service
systems, resulting in improved efficiency and comprehensive care delivery. This success expands beyond
clients and service providers, to Society and through more efficient use of public service resources.
Likewise, burden on public programs could be decreased if dependency, hospitalization, and repeat abuse
in victims were reduced. Through improved agency relationships and expanded public awareness,
beneficial system and cultural change were noted as possible benefits. A return on the initial investment
would bolster community valuation of MDTs, justifying additional resources toward team sustainability
and propagation.
DISCUSSION
This research provides a blueprint for strategic replication and evaluation of EM MDTs, based on
feedback of professionals working the field of elder justice. Guided by Lewin’s force field theory (1951),
resistors and drivers are catalogued from qualitative content analysis of discussion among a panel of
experts and results from a nationwide survey. These findings underscore that MDTs are considered an
essential tool to effectively address EM, demonstrated by one third of survey respondents requesting
guidance starting teams and solving fundamental issues. Most commonly noted resistors to team start up
by survey respondents were lack of public awareness and dedicated funding, and it was believed that
higher level of problem awareness would lead to stakeholder and monetary commitment. Toward MDT
sustainability, key resistors were challenges engaging valued professionals. Law enforcement was most
cited as difficult to recruit, followed by medical professionals and prosecutors. A related resistor to team
sustainability was the challenge of fostering regular attendance and participation among members. Other
notable issues were the need for member training and collaboration, and lack of protocol for effective
case review, such as confidentiality agreement, case selection criteria, and structured format for case
presentation, discussion, and follow-up.
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Although many of these issues have been recognized (Teaster et al., 2003), our findings add to
the literature with collection of specific solutions, many of which already exist or are under development,
as discussed by expert panelists. For instance, the DOJ has assembled a detailed toolkit addressing each of
these aspects of MDTs, available electronically in written and video format, and offers technical support
and one-on-one coaching on developing and maintaining teams (Guinn, T., personal communication,
April 10, 2019), although survey responses suggest this resource is under-utilized. Several survey
respondents requested national EM MDT convenings for sharing best practices and identifying research
priorities. Some are doing this regionally; the New York City Elder Abuse Center hosts bi-monthly
conference calls tailored for MDT facilitators (Breckman, R., personal communication, February 19,
2019). While written and recorded material are helpful resources, it is possible that augmenting this with
interpersonal, individualized support and ongoing telephonic coaching may be effective. Toward strategic
replication, this research supports a model that identifies resistors and corresponding drivers of MDT
replication (figure 3).
Findings also supported an evaluation model, indicating success is defined not solely by
outcomes, but by increments of developing cohesive, sustainable teams. The five themes of success
measurement reflect the five components of a logic model, an evaluation tool used to graphically
represent underlying theory of a program for program design, evaluation, and adaptation (Wholey, Hatry,
& Newcomer, 2010), emphasizing the importance of formative evaluation for MDTs. Improved
understanding of team processes is a key foundation toward a clarity on reasonable expectations for
summative evaluation outcomes. While resources, structure, activities, outputs, and outcomes are
hypothesized in our findings to be linearly related, respondents and expert panelists also suggested non-
linear associations. For example, effective Case Review could foster team member skill development,
further improving member contributions to teamwork, and may also attract additional resources.
Toward unified evaluation of MDTs nationwide, testable hypotheses and research questions are
provided (table 3). The majority were focused on member engagement and team cohesiveness, but there
were also innovative suggestions on holistic, person-centered client outcome measurement and
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hypotheses on societal impact. Incorporation of client perspectives into case planning was noted as
challenging, but essential to increase comprehensiveness and feasibility of case plans. Based on
consensus of experts in research and practice (Sthal, 2015; Breckman, 2015), improved knowledge and
facilitation of victim preferences is the next direction of elder justice. MDTs are a recommended support
to incorporate victim preferences into practice (AGS, 2016), and therefore a strong infrastructure of EM
MDTs will further the aim of person-centeredness.
This research delineates and summarizes core aspects of MDTs as they relate to drivers, barriers,
and measures of success, yet raw data highlights the complexity, indicating MDTs are evolving systems
of emergent learning. Each team may be unique, with varied constellations of participant personalities,
leadership, local agency protocols, regional culture, and geography, each of which were noted to impact
activities, approach, and perceptions of success. Additionally, both survey responses and expert panelist
discussion indicated MDTs are characterized by a process of developmental learning, which occurs on the
level of individual participant, the team, and the organizations to which members belong. As individuals
gain knowledge from other members, their capability and contribution to the team may shift; an effect
that potentially impacts their work unrelated to the team (DeLiema et al., 2016). When members are
replaced, group dynamics change, and the learning begins anew; experienced teams have developed
processes to mitigate transitions (Navarro et al., 2010), yet a new member may improve efficacy by
contributing a new perspective. MDTs are dynamic and complex systems. As such, evaluation methods
that cannot account for aspects of complexity such as non-linearity, dynamic change, emergent learning,
and unpredictability may lose nuanced, yet important lessons, benefits, and unexpected outcomes, and
provide misguided conclusions not necessarily inferable to other teams.
Toward the goal of identifying causality and ensuring accountability in a manner that is flexible
to inherent complexity and flux within MDTs, complexity science provides useful principles. Several
characteristics of complex systems are applicable: emergent change and adaptive stability (Walton, 2013;
Gerrits & Verweij, 2015), social tension with uncertainty in problem-solving, and multiple actors with
varying definitions of success (Gerrits & Verweij, 2015). Identifying “what works” is challenging
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because solutions rely on multiple unpredictable components, and there is a constant flux of adaptation
(Gerrits & Verweij, 2015). Application of complexity to evaluation research notes the importance of
understanding the system and outlying context through a holistic perspective of the intervention over a
long duration. Development and implementation should be concurrent with evaluation, with short- and
long-term feedback. Participatory research aids understanding of the perspectives and value claims of
various actors, for which mixed methods illuminates outcomes and contributing factors (Walton, 2013).
While complexity theory provides a heuristic frame, there is little consensus on specific
characteristics of complexity-informed policy, programs, or evaluation. These theoretical suppositions
require empirical testing to assess value of the application of complexity theory to evaluation, but the
conceptual groundwork is underway. EM MDTs appear to be a valuable partner with research scientists
developing evaluation approaches informed by complexity, toward refining evaluation models that are
adaptable across fields. Rather than answering the question, “Do MDTs work?” perhaps the question is
“How does this MDT work?” with formative evaluation within individual teams to promote learning and
intentional adaptation. To develop an evaluative culture, partnership between MDTs and researchers
could bolster evidence-based design and continual assessment of process and outcome hypotheses. While
lessons may be specific to each individual team, process and evaluation methods would be beneficial to
other teams, which would be bolstered by a national forum for EM MDT facilitators and participants to
share ideas and collaborate.

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CHAPTER V: CONCLUSION
“As human beings, we are all more alike than different...belonging and connection, and creating worth
for others and ourselves, are not only our personal goals and indicators of success, but also must be our
shared primary strategies for increasing safety and wellbeing. Our negative experiences do not define
who we are, or what we want.”
--The Full Frame Initiative (2014)
This dissertation provides foundational exploration of several recognized challenges in EM, about
which no prior research exists. Chapter II examined the process of PCC for EM and found that assuaging
the tension between victim preferences and risk reduction is possible through development of trust
between service provider and victim. Case study analysis revealed that refusal of services by APS was
driven by victim perception that service acceptance was associated with loss of choice and control, which
were prioritized above safety. Chapter III examines the range of issues associated with difficulty
resolving complex EM, and revealed 44 distinct types of challenges. The majority of cases exhibited
multiple issues including health problems, caregiving need, functional decline, behavioral health, housing,
and transportation problems that were not directly related to the EM. These findings underscore the grave
challenges in addressing the most complex EM cases, and the importance of MDTs in assisting with
issues outside the expertise of APS first responders. Chapter IV sought input from EM professionals
nationwide to identify perceived barriers and facilitators to the success of MDTs, finding that lack of
funding, member engagement, and team cohesion were among the most commonly cited problems.
However, informational and technical assistance services were identified that have yet to be broadly
disseminated. Elicitation of definitions of success in EM MDTs revealed the importance and difficulty of
effective teamwork, indicating that incremental success of recruiting a functioning, collaborative team is
itself a laudable achievement. Some of the findings invert assumptions about EM services and outcomes.
EM victim refusal of services heightened safety may require trade-offs of control and social connectivity
that victims are unwilling to relinquish. A closer look at case complexity reveals that among multiple,
urgent issues, abuse may not be perceived as the most pressing to the victim. Support for abusers may be
preferred over punishment, and attempts at improving safety may be perceived by victims as a threat to
existing support systems.
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What is success?
According to the findings in this dissertation, risk-reduction as the focal success of EM
interventions is incomplete. Preferences contributing to EM risk may have underlying motivations such as
maintaining stability and control, intimacy, social connectivity, and victim-defined safety. Under the veil
of high-risk situations were strategic designs meeting important personal needs. Services aimed at
addressing risk may appear to EM victims as a threat to their self-assembled foundation for wellbeing.
Victim refusal of services was a common element of EM complexity in the cases examined in Chapter III,
and reasons cited alluded to the importance of victim independence and existing relationships. Assistance
was accepted with tasks that aligned with victim choices and increased options, such as advocating for
service access and debt alleviation. Most clients were agreeable to periodic visits and telephone calls with
no specific service-oriented aim, indicating that non-remedial approaches may be a more acceptable
approach than focus on problems.
Chapter II underscores the importance of MDTs in facilitating victim choice in tandem with
reduction of abuse risk. Toward replication of MDTs, one of the most commonly cited barriers was
difficulty assembling needed agencies and fostering collaborative relationship. As such, an important
success of EM MDTs is effective teamwork, essential to both the sustainability of the team and ability to
assist victims whose cases are reviewed. Chapter IV findings suggest that formative evaluation of
individual teams is an essential foundation toward outcome evaluation of that team, and identifying key
processes for replication. No two teams are alike, so while success in client outcomes is essential,
knowledge of the incremental successes, such as team development, provide insight on processes driving
outcome findings. Because MDTs are demonstrated in Chapter II to be key in delivery of PCC, bolstering
the infrastructure of teams nationwide is the cornerstone to broaden definitional scope of success to
include victim perspectives.
Recommendations for Person-Centered Care for Victims of Elder Mistreatment
In developing interventions that are conducive to illiciting and facilitating victim-defined goals,
several key processes were identified in Chapter II. For highly complex cases, long-term case
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management appears to be a promising tool for providing PCC, with prioritization of developing client-
practitioner rapport. The cases detailed in Chapter II show this can be accomplished through focus on
victim-identified problems, and trust enabled a more comprehensive understanding of each client’s
motivations and the intentional strategy underlying their choices. Negotiated Consent was a technique that
enabled risk reduction through client preferences (Moody, 1988).
A barrier to implementation of PCC is that processes may run counter to underlying assumptions
and approaches within the current response system. Short term, crisis-focused case management may
make it challenging to establish rapport with some clients. While relationship development might be
accomplished somewhat by repeat referrals to APS (Susman, et al., 2014), if different caseworkers are
sent and interaction is not focused on relationship-building, recurrence could make a victim more
defensive against accepting help (Bergerson, 2006). Standardized response to mandated reports,
vilification of abusers, and exclusive focus on provider-defined safety may also inhibit trust between
client and provider, especially if pursuit of safety appears to compromise other valued needs that are
satisfied with the existing situation. Some forms of assistance desired by victims are not commonly
offered in EM interventions, such as supporting the caregivers suspected of abuse. More research is
needed on intervention approaches acceptable to EM victims. A additional final challenge in PCC for EM
victims is the emotional strain on providers witnessing vulnerable adults in high-risk situations while
helping them with tasks seemingly unrelated to EM.
Mechanisms are needed for eliciting preferences in EM victims with impaired capacity to assure
that preferences aren’t discounted, and that victim preference for risk is not assumed to signify cognitive
impairment. A robust literature supports that adults can express preferences, and benefit from having
control over life circumstances regardless of cognitive decline (Mallers et al., 2014). However, current
culture with focus on protection may preclude seeking to understand multifaced victim needs. This
becomes even more difficult and complex in the face of grave risk and clear impairment. For assuring
self-determination, factors that may be influencing explicit client preferences must be examined for a
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clearer understanding of latent needs and comprehensive, individualized definition of wellbeing
(Bergerson, 2006)
Each of these challenges may be addressed using the support of an MDT with capacity to
coordinate response among agencies, discuss challenging ethical dilemmas, and roundtable systemic
barriers in meeting victim desires. Bolstering national replication of MDTs will be essential in assuring
widespread implementation of PCC for EM victims. Chapter IV identified barriers and drivers toward this
goal. Lack of funding, challenges with MDT member engagement, and fostering effective collaboration
were fundamental resistors to MDT replication and sustainability. However, information and support exist
to address issues related to MDT development and functioning, informed by extensive literature review
and summary of practical advice from those experienced with developing and sustaining MDTs (Jackson,
201c; Connolly & Breckman, 2018; Heisler & Breckman, 2018; Breckman, R. personal communication,
February 19, 2019; Guinn-Schaver, T., personal communication, April 10, 2019). Strategic advice on
funding MDTs also has been provided, such as pooling resources between agencies with common goals,
or illiciting private funds from banks or hospitals. These need further exploration, and a national sweep of
MDTs operating on minimal funding should be done to understand how these teams are sustained, level
of activities and outputs, and measures of success.
These findings are foundational for program design conducive to PCC. Future research is needed
to develop and evaluate concrete definition and processes facilitative to EM PCC in a variety of cases. For
example, mechanisms are needed to reduce bias in determination of whether victim preferences are
“reasonable” for incorporation into case planning. Chapters II and III show the importance of
understanding the context, and the person’s reasoning that underlies their preferences, which may not be
readily clear. Perhaps establishing a semi-structured process of information gathering to enable alternate
solutions that are acceptable to the victim would aid service provider decision-making. Given power
differential between EM victim and service providers, caution must be taken by providers against
assuming to know what is best for the person. Toward this, we underscore the importance of an advocate
who has information on the victim’s preferences and can represent the victim in MDT meetings.
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Complexity: The whole is greater than the sum of the parts
Findings in Chapter III provide a foundation toward development of a complexity scale to
identify cases in need of more intensive intervention. Many problems were identified that increased
difficulty assisting clients, including a wide range of health issues, behavioral health symptoms, financial
mismanagement and poverty, long-term abuse, caregiving need, caregiver impairment, housing instability
and social conflict. In a sample of the most complex cases, issues were not discrete; while they could be
identified as separate conditions, they intermingled such that it would be difficult to resolve one issue
without considering the influences on or from others. For example, early life trauma was discovered in
some with mental illness and emotional dependency; mental illness and cognitive decline limited ability
to self-care and manage finances and maintain stable housing, all of which caused and was exacerbated
by social conflict with neighbors and family. These findings also contextualized the challenges of short-
term crisis intervention services attempting to address highly complex EM. The wide scope of issues
intermingled with EM, requires a more intensive approach for sustainability of solutions. While it may be
helpful to identify distinct characteristics of complexity for quantification, the findings in Ch III clarify
that discrete elements contributing to difficulty within EM cases are interconnected and not easily
addressed by focusing on one, without acknowledging the impact on the others (Smyth, et al., 2006).
Complexity was also observed in MDTs. Chapter IV indicated that teams are dynamic systems
rife with both emergent learning and social tension among individuals, the team, and the agencies to
which each member belongs. The social, economic and infrastructural context in which each team resides
will influence and be impacted by team activity. Complex, dynamic phenomena require equally complex,
dynamic evaluation for a rigorous understanding of not just if an intervention works, but how and why,
and for flexibility in definitions of success (Panos London, 2009).
Future Research: Complexity-Informed Evaluation
Evaluation research on EM interventions is limited, and while there have been several calls for
RTCs or other controlled experimental studies of intervention efficacy (Baker, et al., 2016; Fearing et al.,
2017; Ploeg et al., 2009), reductionist approaches to evaluation may not be a good fit for interventions for
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social problems such as EM that are vastly varied from one another and require individualized
intervention. RTCs are appropriate to evaluate linear cause and effect of standardized treatment in
environments in which possible confounders can be identified, measured, and statistically controlled
(Olsen, Aisner, & MCGinnis, 2007). However, even in medical interventions RTCs are noted by the
Institute of Medicine Roundtable to be useful in a decreasing number of circumstances, and should no
longer be considered the gold standard because of limited generalizability due to variation in population
characteristics, increasing prevalence of multiple complex medical conditions, intervention adaptation,
and cost (Olsen et al., 2007).
This research found non-linearity, emergence, and multiple hidden confounders in both EM cases
and MDTs. Social conflict and tension, competing measures of success, and emergent learning are
inherent characteristics contributing to unpredictable states of flux and stability (Panos London, 2009;
Walton, 2015). In EM cases, even two cases that appear very similar in substantive qualities may have
diverse reactions to an intervention. Reliance on RTCs as the sole form of evaluation risks losing nuanced
successes and programmatic learning and individualized definitions of success (Smyth & Schorr, 2009;
Goodman, Epstein, & Sullivan, 2018). Chapter II findings showed that success in facilitating victim
preferences was minimally successful when viewed solely through a lens of risk-reduction. If success in
predetermined outcomes is demonstrated, results will have limited inference to similar environments,
which is problematic if evaluations are primarily conducted in resource-rich areas.
Literature review of complexity-informed evaluation finds that mixed-methodology, participatory
research and utilization of both short- and long-term outcome measurement are useful in understanding
phenomena in states of change. Evaluation should occur concurrently with program development, with
adaptations in program informing adaptation in measurement methods (Walton, 2015). Participatory
methods and iterative cycles of learning and action among program participants, first line responders, and
researchers are recommended (Panos, 2009; Walton, 2015; Goodman, et al., 2018; Full Frame Initiative,
2015) and generating resonance of narrative story representing both the problem and solution, testing with
multiple audiences may assist in building a rich picture of mechanisms (Panos, 2009). A researcher-
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practitioner learning collaborative model established among Domestic Violence researchers was used to
develop and validate an outcome measure reflecting both survivor goals and provider mission (Goodman,
Cataneo, Thomas, Woulfe, Chong, & Smyth, 2015), has promising application to EM (Thomas,
Goodman, Vainer, Heimel, Barkai, Collins-Gousby, 2018). Collaboration among all participants is
necessary to develop program design and measures of success with applicability to all those involved.

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REFERENCES
Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., Kilpatrick, D. G.
(2010). Prevalence and Corelates 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 American Geriatrics Society Expert Panel on Person-Centered Care (2017). Person-Centered Care: A
Definition and Essential Elements. The Journal of the American Geriatric Society, 64, 15-18.
DOI: 10.1111/jgs.13866
Anetzberger, G. J. (2011). The evolution of a multidisciplinary response to elder abuse. Marq. Elder's
Adviser, 13(1), 107.
Baker, P. R. A., Francis, D. P., Hairi, N. N., Othman, S., & Choo, W. Y. (2016). Interventions for
preventing abuse in the elderly. Cochrane Database of Systematic Reviews, (8), CD010321.
doi:10.1002/14651858.CD010321.pub2
Barker, N. N., & Himchak, M. V. (2006). Environmental issues affecting elder abuse victims in their
reception of community based services. Journal of Gerontological Social Work, 48, 233-255.
doi:10.1300/J083v48n01_16
Baulaurier, R. L., Seff, L. R., Neewman, F. L., & Dunlop, B. (2007) External Barriers to Help Seeking for
Older Women Who Experience Intimate Partner Violence. Journal of Family Violence, 22, 747-
755.
Benson, B., & Quinn, K. (2012). “Federal Responses Needed to Meet the Significant Challenges Facing
State and Local Adult Protective Services.” [White Paper]. Washington, D. C. Elder Justice
Coordinating Council.
Bergerson (2006). Self-Determination and Elder Abuse: Do we know enough? Journal of Gerontological
Social Work, 46:3-4, 81-102, DOI: 10.1300/J083v46n03_05
Breckman, R., Callanhan, J., & Solomon, J. (2015). "Planning for the Future." [White paper]. Retrieved
from https://brookdale.org/wp-content/uploads/2016/01/planning-for-the-future.pdf
Rowan Dissertation – Fall 2019 81

Breckman, R., Burnes, D., Ross, S., Marshall, P., Suitor, J., Lachs, M., and Pillemer, K. (2017). When
Helping Hurts: Nonabusing Family, Friends, and Neighbors in the Lives of Elder Mistreatment
Victims. The Gerontologist, 00:00, 1-5. doi:10.1093/geront/gnw257
Burnes, D., Rizzo, V. M., Courtney, E. (2014). Elder Abuse and Neglect Risk Alleviation in Protective
Services. Journal of Interpersonal Violence, 29 (11), 2091-2113. DOI:
10.1177/0886260513516387
Burnes, D., Rizzo, V. M., Gorroochurn, P., Pollack, M. H., & Lachs, M. S. (2016). Understanding service
utilization in cases of elder abuse to inform best practices. Journal of Applied Gerontology,
35(10), 1036-1057. doi:10.1177/0733464814563609
Burnes, D., & Lachs, M. S. (2017). The Case for Individualized Goal Attainment Scaling Measurement in
Elder Abuse Interventions. The Journal of Applied Gerontology, 36(1), 116-122.
David Burnes, Mark S. Lachs, Denise Burnette, Karl Pillemer, (2016). Varying Appraisals of Elder
Mistreatment Among Victims: Findings from a Population-Based Study. The Journals of
Gerontology: Series B, gbx005, https://doi.org/10.1093/geronb/gbx005
Burnes, D. (2017). Community elder mistreatment intervention with capable older adults: Toward a
conceptual practice model. Gerontologist, 57(3), 409-416. doi:10.1093/geront/gnv692
Burnett, J., Jackson, S. L., Sinha, A. K., Aschenbrenner, A. R., Murphy, K. P., Xia, R., & Diamond, P. M.
(2016). Five-year all-cause mortality rates across five categories of substantiated elder abuse
occurring in the community. Journal of Elder Abuse & Neglect, 28(2), 59-75.
doi://dx.doi.org.libproxy2.usc.edu/10.1080/08946566.2016.1142920
Connolly, Marie-Therese, Brandl, Bonnie, and Breckman, Risa (2014). The Elder Justice Roadmap.
Department of Justice. https://www.justice.gov/file/852856/download
Connolly, M. T., and Breckman, R. (2018). The Role of Local Prosecutors on Elder Abuse
Multidisciplinary Teams. New York City Elder Abuse Center & Weill Cornell Medicine. New
York, NY.
Rowan Dissertation – Fall 2019 82

DeLiema, Marguerite (2017). Elder Fraud and Financial Exploitation: Application of Routine Activity
Theory. The Gerontologist, Advance Access publication March 10, 2017.
doi:10.1093/geront/gnw258
DeLiema, M., Navarro, A., Moss, M., & Wilber, K. (2016). Prosecutors’ Perspectives on Elder Justice
Using an Elder Abuse Forensic Center. The American Journal of Criminal Justice, 41:780-795.
DOI 10.1007/s12103-015-9321-7
DeLiema, M., Navarro, A., Enguidanos, S., & Wilber, K. (2015). Voices from the Frontlines: Examining
Elder Abuse from Multiple Professional Perspectives. National Association of Social Workers,
40(2), doi: 10.1093/hsw/hlv012
DeLiema, M., Yonashiro-Cho, J., Gassoumis, Z., Yon, Y., & Conrad, K. (2018). Using Latent Class
Analysis to Identify Profiels of Elder Abuser Perpetrators. The Journals of Gerontology: Series B,
73:5, edoi:10.1093/geronb/gbx023
Dong, X. (2015). Elder abuse: Systematic review and implications for practice. Journal of the American
Geriatrics Society, 63(6), 1214-1238. doi:10.1111/jgs.13454
Dooley, D. V., & Radke, M. (2010). Does severe punishment deter financial crimes? Charleston Law
Review, 4, 619-659.
Elder Abuse and Dependent Adult Civil Protection Act, CA W.I.C. § 15633-15637 (1991). Retrieved
from
https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC§ionNum
=15633
Ernst, J. S., Smith, C. A. (2012). Assessment in Adult Protective Services: Do Multidisciplinary Teams
Make a Difference? Journal of Gerontological Social Work, 55(21-38).
Ernst, J., Ramsey-Klawsnik, H., Schillerstrom, J., Dayton, C., Mixson, P., Counihan, M. (2014).
Informing Evidence-Based Practice: A Review of Research Analyzing Adult Protective Services
Data. Journal of Elder Abuse & Neglect, 26, 458-494. DOI: 10.1080/08946566.2013.832605
Rowan Dissertation – Fall 2019 83

Fazio, S., Pace, D., Flinner, J., & Kallmyer, B. (2018). The Fundamentals of Person-Centered Care for
Individuals with Dementia. The Gerontologist, 58, suppl_1, s10-s19.
https://doi.org/10.1093/geront/gnx122
Fearing, G., Sheppard, C., McDonald, L., Beaulieu, M., Hitzig, S. (2017). A systematic review on
community-based interventions for elder abuse and neglect. Journal of Elder Abuse and Neglect,
29:2-3, 102-133, DOI: 10.1080/08946566.2017.1308286
Finfgeld-Connett, D. (2014). Intimate Partner Abuse Among Older Women: Qualitative Systematic
Review. Clinical Nursing Research, 23(6). DOI: 10.1177/1054773813500301
Fink, A., Kosecoff, J., Chassin, M., & Brook, R. H. (1984). Consensus Methods: Characteristics and
Guidelines for Use. The American Journal of Public Health, 74:9, 979-983.
Gassoumis, Z. D., Navarro, A. E., & Wilber, K. H. (2015). Protecting victims of elder financial
exploitation: The role of an elder abuse forensic center in referring victims for
conservatorship. Aging & mental health, 19(9), 790-798.
Gerrits, L., Verweij, S. (2015). Taking stock of complexity in evaluation: A discussion of three recent
publications. Evaluation, 21(4), 481-491.
Goodman, L. A., Cattaneo, L. B., Thomas, K., Foulfe, J. Chong, S. K., & Smyth, K. F. (2015). Advancing
Domestic Violence Program Evaluation Development and Validation of the Measure of Victim
Empowerment Related to Safety (MOVERS). Psychology of Violence, 5(4), 355-366.
http://dx.doi.org/10.1037/a0038318
Goodman, L., Epstein, D., & Sullivan, C. M. (2018). Beyond the RTC: Integrating Rigor and Relevance
to Evaluate the Outcomes of Domestic Violence Programs. American Journal of Evaluation,
39(1), 58-70. DOI: 10.1177/1098214017721008
Hamby, S., Smith, A., Mitchell, K., & Turner, H. (2016). Poly-victimization and resilience portfolios:
Trends in violence research that can enhance the understanding and prevention of elder abuse.
Journal of Elder Abuse & Neglect, 28,4-5, 217-234.
Rowan Dissertation – Fall 2019 84

Haslbeck, J. W., McCorkle, R., & Schaeffer, D. (2012). Chronic Illness Self-Management While Living
Alone in Later Life: A Systematic Integrative Review. Research on Aging, 34(5), 507-547. DOI:
10.1177/0269758016630887
Heisler, C. (2018). Moving forward: recommendations for advancing late-life polyvictimzation practice,
policy, and research. Journal of Elder Abuse and Neglect, 29(5), 351-363. DOI:
10.1080/08946566.2017.1388013
Heisler, C., and Breckman, R. (2018). The Role of Civil Attorneys on Elder Abuse Multidisciplinary
Teams. New York City Elder Abuse Center & Weill Cornell Medicine, New York, NY.
Hightower, J., Smith, M. J., & Hightower, H. C. (2006). Hearing the Voices of Abused Older Women.
Journal of Gerontological Social Work, 46:3-4, 205-227.
Jackson, S. L., and Hafemeister, T. L. (2011). Risk Factors Associated With Elder Abuse: The
Importance of Differentiating by Type of Elder Mistreatment. Violence and Victims, 26:6, 738-
757.
Jackson, S. (2016a) All Perpetrators Are Not Alike: The Heterogeneity of Elder Abuse Perpetrators and
Implications for Intervention. International Journal of Offender Therapy and Comparative
Criminology, 60(3), 265-285. DOI: 10.1177/0306624X14554063
Jackson, S. (2016b). The shifting conceptualization of elder abuse in the united states: From social
services, to criminal justice, and beyond. International Psychogeriatrics, 28(1), 1-8.
//dx.doi.org.libproxy1.usc.edu/10.1017/S1041610215001271 Retrieved from
http://libproxy.usc.edu/login?url=https://search-proquest-
com.libproxy1.usc.edu/docview/1738843370?accountid=14749
Jackson, S. (2016c). Elder Abuse Case Review Toolkit. Retrieved from
https://www.justice.gov/elderjustice/file/938921/download
Jackson, S. L. (2017). Adult protective services and victim services: A review of the literature to increase
understanding between these two fields. Aggression and Violent Behavior, 34, 214.
Rowan Dissertation – Fall 2019 85

Kehoe, E., & Egan, J. (2019). Interpersonal attachment insecurity and emotional attachment to
possessions partly mediate the relationship between childhood trauma and hoarding symptoms in
a non-clinical sample. Journal of Obsessive-Compulsive and Related Disorders, 21, 37–45.
https://doi.org/10.1016/j.jocrd.2018.12.001
Kogan, A. C., Wilber, K., & Mosqueda, L. (2015a). Moving Toward Implementation of Person-Centered
Care for Older Adults in Community-Based Medical and Social Service Settings: “You Only Get
Things Done When Working in Concert with Clients”. The Journal of the American Geriatric
Association, 64, e8-e14. DOI: 10.1111/jgs.13876
Kogan, A. C., Wilber, K., & Mosqueda, L. (2015b). Person-Centered Care for Older Adults with Chronic
Conditions and Functional Impairment: A Systematic Literature Review. The Journal of the
American Geriatric Association, 64, e1-e7. DOI: 10.1111/jgs.13873
Kumar, A. (2016). Older people’s experiences and perspectives of elder abuse: what’s next? Age and
Ageing, 45, 572-573. doi: 10.1093/ageing/afw121
Lachs, M. S., Williams, C. S., O’Brien, S., & Pillemer, K. A. (2002). Adult Protective Service Use and
Nursing Home Placement. The Gerontologist, 42(6), 734-739.
Lachs, M. S., & Berman, J. (2011). Under the radar: New York State elder abuse prevalence study.
Retrieved from New York City Elder Abuse Center: http://nyceac.com/wp-
content/uploads/2011/05/UndertheRadar051211.pdf
Lewin, K. (1951). Field theory in social science. New York: Harper & Row.
Lewin, K. (1958). Group decision and social change. In E. Maccoby, T. Newcomb, E. Harley (Eds.),
Readings in social psychology. New York: Holt & Co.
Mallers, M. H., Claver, M., & Lares, L. A (2014). Perceived Control in the Lives of Older Adults: The
Influence of Langer and Rodin’s Work on Gerontological Theory, Policy, and Practice. The
Gerontologist, 54(1), 67-74. doi:10.1093/geront/gnt051
MetLife Study of Elder Financial Abuse: Crimes of Occasion, Desperation, and Predation Against
America’s Elders. (2011, June). Retrieved from
Rowan Dissertation – Fall 2019 86

https://www.metlife.com/assets/cao/mmi/publications/studies/2011/mmi-elder-financial-
abuse.pdf
Moody, H. R. (1988). From Informed Consent to Negotiated Consent. The Gerontologist, 28, Suppl., 64-
70.
Mosqueda, L. (2012). How the Federal Government can Encourage and Facilitated the Development of
Interdisciplinary Team Responses to Elder Abuse. [White paper]. Washington, D. C. Elder
Justice Coordinating Council.
Mosqueda, L., Burnight, K., Gironda, M. W., Moore, A. A., Robinson, J., & Olsen, B. (2016). The abuse
intervention model: A pragmatic approach to intervention for elder mistreatment. Journal of the
American Geriatrics Society, 64(9), 1879-1883. doi:10.1111/jgs.14266
National Adult Protective Services Association [NAPSA] Education Committee (2013). Adult Protective
Services Recommended Minimum Program Standards.
Navarro, A. E., Wilber, K. H., Yonashiro, J., & Homeier, D. C. (2010). Do we really need another
meeting? Lessons from the Los Angeles county elder abuse forensic center. The Gerontologist,
50(5), 702.
Navarro, A. E., Gassoumis, Z. D., & Wilber, K. H. (2012). Holding abusers accountable: An elder abuse
forensic center increases criminal prosecution of financial exploitation. The Gerontologist, 53(2),
303-312.
Navarro, A. E., Wysong, J., DeLiema, M., Schwartz, E. L., Nichol, M. B., & Wilber, K. H. (2015). Inside
the black box: The case review process of an elder abuse forensic center. The Gerontologist,
56(4), 772-781.
Oliver, S., Burls, T., Fenge, L., & Brown, K. (2015). “Winning and Losing”: vulnerability to mass
marketing fraud. Journal of Adult Protection, 17(6), 360-370.
Olsen, LeighAnne, Aisner, Dara, & McGinnis, J. Michael. (2007). Institute of Medicine Roundtable on
Evidence-Based Medicine: The Learning Healthcare System, Workshop Summary. Washington
DC, National Academies Press.
Rowan Dissertation – Fall 2019 87

Padgett, D. K. (2012). Qualitative and Mixed Methods in Public Health. Thousand Oaks, California: Sage
Publications, Inc.
Panos London (2009). How can complexity theory contribute to more effective development and aid
evaluation? Retrieved from workshop summary:
https://aidontheedge.files.wordpress.com/2009/10/panos-london-complexity-and-evaluation-
dialogue.pdf
Pillemer, K., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder abuse: Global situation, risk factors,
and prevention strategies. Gerontologist, 56, S205. doi:10.1093/geront/gnw004
Ploeg, J., Fear, J., Hutchinson, B., MacMillian, H., Bolran, G., (2009). A Systematic Review of
Interventions for Elder Abuse. Journal of Elder Abuse & Neglect, 21(3), 187-210. DOI:
10.1080/08946560902997181
Ramsey-Klawsnik, H. (2017). Older adults affected by polyvictimization: a review of early
research. Journal of elder abuse & neglect, 29(5), 299-312.
Robinson, P. H., & Darley, J. M. (2004). Does criminal law deter? A behavioural science investigation.
Oxford Journal of Legal Studies, 24, 173-205.
Rizzo, V., Burnes, D., & Chalfy, A. (2015). A systematic evaluation of a multidisciplinary social work-
lawyer elder mistreatment intervention model. Journal of Elder Abuse & Neglect, 27(1), 1-18.
doi:10.1080/08946566.2013.792104
Sandmoe, A., Hauge, S. (2014). When the struggle against dejection becomes a part of everyday life: a
qualitative study of coping strategies in older abused people. Journal of Multidisciplinary Health
care, 7, 283-291.
Schneider, D. C., Mosqueda, L., Falk, E., & Huba, G. J. (2010). Elder abuse forensic centers. Journal of
Elder Abuse & Neglect, 22(3-4), 255-274.
Smyth, K., Goodman, L., & Glenn, C., (2006). The Full-Frame Approach: A New Response to
Marginalized Women Left Behind by Specialized Services. American Journal of
Orthopsychiatry, 76(4) 489-502.
Rowan Dissertation – Fall 2019 88

Smyth, K. & Schorr, E. (2009). A Lot to Lose: A Call to Rethink What Constitutes “Evidence” in Finding
Social Interventions that Work. Harvard Kennedy School; Malcom Wiener Center for Social
Policy; Working Paper Series. www.hks.harvard.edu/socpol/publications_main.html
Stahl, S. M. (2015). Building Consensus on Research Priorities in Elder Mistreatment United States
Department of Justice, July 2015.
Susman, A., Lees, K., & Fulmer, T. (2015). Understanding repeated visits to adult protective services.
The Journal of Adult Protection, 17(6), 391-399.
Stetler, C. B., Legro, M. W., Wallace, C. M., Bowman, C., Guihan, M., Hagedorn, H., Kimmel, B.,
Sharp, N. D., Smith, J. L. (2006). The Role of Formative Evaluation in Implementation Research
and the QUERI Experience. Journal of General Internal Medicine, 21:s1-8. DOI: 10.1111/j.1525-
1497.2006.00355.x
Teaster, P. B., Nerenberg, L. and Kim L. Stansbury (2003) A National Look at Elder Abuse
Multidisciplinary Teams, Journal of Elder Abuse & Neglect, 15:3-4, 91-107, DOI:
10.1300/J084v15n03_06
Terracina, K. A., Aamodt, W. W., Schillerstrom, J. E. (2015). Executive Function Impairment and
Recidivism in Adult Protective Services Clients Referred for a Decision Making Capacity
Assessment. Journal of Elder Abuse & Neglect, 27(2), 91-99.
Teresi, J., Burnes, D., Skowron, E., Dutton, M., Mosqueda, L., Lachs, M., & Pillemer, K., (2016). State of
the science on prevention of elder abuse and lessons learned from child abuse and domestic
violence prevention: Toward a conceptual Framework for research. Journal of Elder Abuse &
Neglect, 28:4-5, 263-300.
Thomas, K. A., Goodman, L., A., Vainer, S. E., Heimel, D., Barkai, R., Collins-Gousby, D. (2018). “No
Sacred Cows or Bulls”: The Story of the Domestic Violence Program Evaluation and Research
Collaborative (DVPERC). Journal of Family Violence, 33, 537-549.
https://doi.org/10.1007/s10896-018-9978-z
Rowan Dissertation – Fall 2019 89

United States Administration for Community Living (2018). About ACL. Mission and Strategic Plan.
Retrieved from https://acl.gov/about-acl
United States Administration for Community Living, Final National Voluntary Consensus Guidelines for
State Adult Protective Services Systems, September 2016. Washington, D.C. 20201
United States Elder Justice Act [EJA], 2010.
United States Government Accountability Office [GAO] (2010). Elder justice: stronger federal leadership
could enhance national response to elder abuse. http://aging.senate.gov/letters/d11208.pdf.
Accessed January 26, 2013.
Wholey, J. S., Hatry, H. P., & Newcomer, K. E., (2010). Handbook of Practical Program Evaluation. San
Francisco, CA: Jossey-Bass.
Wiglesworth, A., Mosqueda, L., Burnight, K., Younglove, T., & Jeske, D. (2006). Findings from an elder
abuse forensic center. The Gerontologist, 46(2), 277-283.
Walton, M. (2015). Applying complexity theory: A review to inform evaluation design. Evaluation and
Program Planning, 45, 119-126.
Yon, Y., Mikton, R. C., Gassoumis, Z. D., and Wilber, K. H. (2017). Elder abuse prevalence in
community settings: a systematic review and meta-analysis. The Lancet Global Health, 5, e147-
56.

Abstract (if available)

Abstract Elder mistreatment (EM) effects approximately 5 million older adults in the US each year (Acierno et al., 2010), with enormous costs to victims (Pillemer, Burnes, Riffin, & Lachs, 2016), society (Dong, 2015

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Asset Metadata

Creator Rowan, Julia Margaret (author)

Core Title What is success? an exploration of person-centered intervention of complex elder mistreatment

School Leonard Davis School of Gerontology

Degree Doctor of Philosophy

Degree Program Gerontology

Publication Date 12/16/2019

Defense Date 12/16/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag elder mistreatment,intervention,multidisciplinary teams,OAI-PMH Harvest,person-centered care

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Wilber, Kathleen (committee chair), Enguidanos, Susan (committee member), Gassoumis, Zachary (committee member)

Creator Email julia.m.rowan@gmail.com,wysong@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-254944

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Identifier etd-RowanJulia-8075.pdf (filename),usctheses-c89-254944 (legacy record id)

Legacy Identifier etd-RowanJulia-8075.pdf

Dmrecord 254944

Document Type Dissertation

Rights Rowan, Julia Margaret

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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