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Developing a better understanding of elder abuse multidisciplinary teams: addressing gaps for research, policy, and practice

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Developing a better understanding of elder abuse multidisciplinary teams: addressing gaps for research, policy, and practice

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DEVELOPING A BETTER UNDERSTANDING OF ELDER ABUSE
MULTIDISCIPLINARY TEAMS: ADDRESSING GAPS FOR RESEARCH, POLICY, AND
PRACTICE

by

Gerson Galdamez
________________________________________________________

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 2020

ii
DEDICATION

To Roger Dale Garten
Who inspired me to exceed expectations.

iii
ACKNOWLEDGEMENTS
This dissertation was made possible by the support of a grant from the U.S.
Administration for Community Living and a 4-year fellowship from the Robert Wood Johnson
Health Policy Research Scholars Program.
I would like to thank my family: my parents Dan & Ethel, my grandmothers Sara and
Carlene, my sister Stefanie, and my partner Kennedy for years of unconditional encouragement
and understanding. My other family—Mat, Cole, Robert, Lawrence, Evan, Connor, and Kenan—
provided welcome refuge from my journey, full of laugher and needed distraction. Thank you to
my PhD cohort—Laura, Kristi, and Carly, the “Fantastic Four”—with whom I shared struggles
and triumphs. Thank you to my HPRS cohort—specifically Emanuel, Matt, and Austin—for
their support and refreshing perspective on my research. Thank you to my fellow Trojans and
USC Climbing teammates—Jeremy Dietrich, Danny Stirton, and many others—who let me sleep
on their couches as I was paying my way through my undergraduate studies.
I would like to thank Maria Henke and the Leonard Davis School of Gerontology for
their investment in me over the past seven years. I am grateful to Haley Gallo, Liz Avent, Meki
Singleton, Kylie Meyer, Jeanine Yonashiro-Cho, Yongjie Yon, Laura Mosqueda, Gretchen
Alkema, Erin Westphal, Megan Burke, Bruce Chernoff, Christopher Langston, Joe Prevratil,
Mary Ellen Kullman, and many others whose professional wisdom and personal friendships have
allowed me to thrive in this program. Thank you to Dr. Reginald Tucker-Seeley for his guidance
and input on this work. Lastly, I would like to thank my mentors, Drs. Kathleen Wilber and
Zachary Gassoumis. I am privileged to have had their teaching, guidance, and support
throughout my undergraduate and graduate studies at USC. Their many years of patience and
leadership have helped me grow professionally and personally. I would not be the scholar I am
today without them.
iv
TABLE OF CONTENTS

DEDICATION ................................................................................................................................ ii
ACKNOWLEDGEMENTS ........................................................................................................... iii
LIST OF TABLES AND FIGURES .............................................................................................. v
ABSTRACT ................................................................................................................................... vi
CHAPTER 1: INTRODUCTION ................................................................................................... 1
CHAPTER 2: A NATIONAL DESCRIPTIVE STUDY OF ELDER ABUSE
MULTIDISCIPLINARY TEAMS IN THE U.S. ......................................................................... 13
CHAPTER 3: USING LATENT CLASS ANALYSIS TO IDENTIFY TYPES OF ELDER
ABUSE MULTIDISCIPLINARY TEAMS ................................................................................. 37
CHAPTER 4: PERSPECTIVES FROM AROUND THE TABLE: A DESCRIPTIVE STUDY
ON ELDER ABUSE MULTIDISCIPLINARY TEAM MEMBERS .......................................... 66
CHAPTER 5: CONCLUSIONS ................................................................................................... 97
REFERENCES ........................................................................................................................... 104
APPENDIX A: CHAPTER 2 INSTRUMENT ........................................................................... 110
APPENDIX B: CHAPTER 3 INSTRUMENT ........................................................................... 116
APPENDIX C: FIT STATISTICS FOR LCA ............................................................................ 131
APPENDIX D: FIGURE 3.2. ILLUSTRATING RESPONSE PROBABILITIES FOR LCA
MODELS WITH 2, 3, & 4 CLASSES ....................................................................................... 132
APPENDIX E: MDT LIST BY NAME AND CATEGORY ..................................................... 133
APPENDIX F: CHAPTER 4 INSTRUMENT ........................................................................... 134

v

LIST OF TABLES AND FIGURES
Figure 1.1. The Elder Abuse Forensic Center Conceptual Model 9
Figure 2.1. The Elder Abuse Forensic Center Conceptual Model 17
Figure 2.2. U.S. Map Visualization of Elder Abuse MDTs by State 27
Figure 3.1. The Elder Abuse Forensic Center Conceptual Model 38
Figure 3.2. Response Probabilities for LCA with 2, 3, & 4 Classes (APPENDIX D) 128
Figure 5.1. Conceptual Framework for Implementation (Fixsen et al. 2005) 96
Table 2.1. Characteristics of Respondents Involved in Elder Abuse 25
Table 2.2. MDT Characteristics 28
Table 2.3. Perceptions of MDTs 30
Table 2.4. Perceptions of MDTs (cont.) 31
Table 3.1. Descriptive Statistics of Items Used for MDT Latent Classes (N=81) 45
Table 3.2. MDT Characteristics (N=81) 48
Table 3.3. MDT Meeting Characteristics (N=81) 51
Table 3.4. MDT Professions and Meeting Attendance 52
Table 3.5. Item Response Probabilities for a 3-Class Model of EA MDTs (N=81) 55
Table 3.6. Characteristics Conditional on MDT Class Membership (N=81) 56
Table 3.7. Characteristics Conditional on MDT Class Membership (N=81) 57
Table 3.8. Fit Statistics for a Latent Class Analysis of EA MDTs (APPENDIX C) 127
Table 4.1. MDT Member Characteristics 73
Table 4.2. MDT Case Review Process: MDT Member Perspectives 76
Table 4.3. MDT Characteristics and Impacts 78
Table 4.4. Results of Adapted Team Effectiveness Inventory 80
Table 4.5. Member Perspectives on MDT Establishment 81
Table 4.6. Differences in Responses by Respondent Education 83
Table 4.7. Differences in Responses by Respondent Elder Abuse Case Experience (Prior
to MDT Membership)
85
Table 4.8. Differences in Responses by Respondent Professional Group 87

vi
ABSTRACT
Elder abuse and mistreatment are pervasive public health problems that negatively affect
the well-being of 1 in 10 older adults in the United States (Acierno et al., 2010; Lachs et al., 1997).
Elder abuse cases can involve several types of abuse (physical, emotional, financial, sexual, and
neglect) occurring at once, and can require myriad social, medical, and legal services to resolve
(Connolly, 2010). Elder Abuse Multidisciplinary Teams (EA MDTs) are a cornerstone
intervention in the elder abuse field, but knowledge of this intervention is limited. Building an
evidence base for these teams is a necessary component of MDT replication and improvement.
This dissertation presents three individual chapters that contribute to this growing body of
knowledge by 1) providing national-scale descriptive data on MDTs in the U.S. 2) distinguishing
and clarifying a promising model of MDT (the Elder Abuse Forensic Center) and 3) providing
novel descriptive data on MDT team members.
In the first empirical chapter, snowball sampling was used to survey 508 elder abuse-
related professionals across the country on their knowledge of existing elder abuse MDTs.
Respondents identified 324 unique MDTs in the United States. Findings show that elder abuse
MDTs focus most on financial exploitation (90.8% of teams), followed by physical abuse
(83.58%) and neglect by other (81.59%). The most common perceived barrier to MDTs was
funding/resources (35.8% of teams), followed by time commitment (30.56%) and agency
engagement (22.84%). As the first study to identify the prevalence and perceptions of different
elder abuse MDT models, this research can be used to inform policy makers on effective elder
abuse interventions and identify gaps to be filled through policy action.
With the passage of the Elder Justice Act of 2010, the Federal Government included
budgetary provisions in support of a particularly promising model of MDT: The Elder Abuse
vii
Forensic Center (EAFC). Although the EAFC model has been implemented at four sites in
California with promising outcomes, the specific structures, processes, and practices that
currently define this model have not been validated with studies of other MDTs in the United
States. In the second empirical chapter, 81 elder abuse MDT key informants were surveyed
across the country, using the most current EAFC conceptual model to guide instrument
development (Yonashiro-Cho et al., 2019). We then used Latent Class Analysis (LCA ) to group
these teams based on EAFC model characteristics. We hypothesized that elder abuse MDTs
would fall on a continuum: those that were identical or nearly identical to the EAFC model,
those that had some EAFC qualities, and those that were clearly distinct from this model. Results
of the LCA supported our hypothesis and revealed three types of elder abuse MDTs: EAFCs
(n=26), Semi-EAFCs (n=24), and Non-EAFCs (n=31). Policy makers, advocates, and
professionals seeking to form new teams or support existing teams can draw on these findings to
make decisions about MDT design, development, implementation, and sustainability.
In the third empirical chapter, 75 MDT members were surveyed on four domains:
demographic information, the case review process, MDT success, and MDT creation. Most MDT
members surveyed had high levels of education (undergraduate or graduate degrees), worked for
social services, and had varying levels of elder abuse experience. Common motivations for
joining MDTs included requirements set by the employer, and the need for assistance on
complex cases. Client safety and protection was identified as the top priority in case decision
making. MDT success was rated positively, and respondents believed they contributed to this
success. Findings also demonstrate that respondents do not feel their MDT has the necessary
resources to reach its goals. Responses on MDT creation suggests funding, agency recruitment,
and finding cases for review are barriers to new MDTs. This chapter provides seminal detail on
viii
EA MDT culture from the perspective of its members and can be used for the improvement of
existing teams and establishment of new teams.
To summarize, this dissertation contributes needed knowledge on the evolving landscape
of EA MDTs. Although these findings highlight the value of EA MDTs, they also underscore the
lack of resources provided to this intervention. As attention to elder abuse issues and
interventions grows, it will be necessary to provide evidence-based information for effective
implementation and support.
1
CHAPTER 1: INTRODUCTION
Elder Abuse: A Multifaceted Problem
Elder abuse (EA) is a compelling public health, safety, and wellness issue that can
devastate the lives of older adults and their loved ones (Button et al., 2010; Deem, 2000). This
phenomenon holds severe negative consequences to an older adult’s physical and mental health,
including increased risk of death (Dong et al. 2009, Lachs et al., 1998; Pillemer et al., 2016).
Elder abuse also adversely affects health and social services systems in cases that require high
resource utilization, particularly if those cases are recurring (Dong et. al., 2015). Relatedly, elder
financial fraud incurs a cost of 50 billion dollars each year (Financial Fraud Research Center,
2012). Although prevalence studies estimate that 1 in 10 older adults are victims of elder abuse
in the U.S., low identification and reporting may be masking a much higher prevalence rate
(Acierno et al., 2010). As the United States experiences rapid growth in the older adult
population, it is imperative that this problem is recognized, understood, and addressed.
Elder abuse is multifaceted, and therefore difficult to detect and resolve. Elder abuse is
generally defined as “intentional actions that cause harm or create serious risk of harm, whether
or not intended, to a vulnerable elder by a caregiver or other person who stands in a trust
relationship to the elder” (Bonnie & Wallace, 2003). This is further delineated into five abuse
types: “(a) physical abuse, which includes acts carried out with the intention to cause physical
pain or injury; (b) psychological abuse, defined as acts carried out with the intention of causing
emotional pain or injury; (c) sexual assault; (d) material exploitation, involving the
misappropriation of the elder’s money or property; and (e) neglect, or the failure of a designated
caregiver to meet the needs of a dependent older person” (Council, 2013; Lachs et al., 1997;
2
Pillemer, 2016). “Psychological” abuse is often used interchangeably with “emotional” abuse,
and “material” exploitation with “financial” exploitation (DeLiema, 2018).
In addition, the phenomenon of self-neglect—defined as “the failure (voluntary or not) to
provide oneself with basic care and protection”—is sometimes included as a type of elder abuse
(Dong, 2017). Although self-neglect involves a fundamentally different dynamic (the older adult
is both the victim and the perpetrator), it is commonly reported to APS, positively associated
with morbidity and mortality, and warrants attention from research and practice focused on older
adult well-being (Mosqueda & Dong, 2011).
In elder abuse cases, these abuse types can often intersect, complicating the path toward
successful outcomes. Additionally, emotional and/or instrumental dependence between the
perpetrator and victim is important to consider even though it may complicate the process toward
a successful outcome (Fingfeld-Connet, 2014). However, because the wishes of an elder abuse
victim may conflict with professionals’ and others’ assessments of the older adult’s basic health
needs, it may be difficult for those trying to help to reach an appropriate or ethical decision about
how to best support the older adult. This presents a unique challenge with various social, legal,
and medical facets, supplemented by the difficulty in defining a “successful” outcome for cases.
Siloed professional fields that encounter elder abuse cases in daily practice encounter myriad
moving pieces that are difficult to sort out and act on, especially if those involved are unaware of
what others are doing to help.
Due to this complexity, solutions may require intervention from a variety of social, legal,
and medical fields that do not normally work together (Connolly, 2010). Although Adult
Protective Services (APS) and long-term care ombudsmen serve as the primary reporting entities
for elder abuse cases, they lack the bandwidth and expertise to fully address the details of
3
complex cases or conceptualize solutions. Because social, legal, and medical professional fields
often operate independently, the multidisciplinary team approach has become a vehicle that
brings professionals from diverse fields together (Connolly, 2010; Wilber, Navarro, &
Gassoumis, 2014). The availability of multiple professional perspectives on a case, in addition to
the various administrative capabilities and service provisions of different professions, present a
promising solution to complex elder abuse cases.
Multidisciplinary Teams: A History and Review of Literature
The Elder Abuse Multidisciplinary Teams (EA MDTs) are groups of professionals from
different disciplines that come together to addresses elder abuse. This multidisciplinary approach
to providing “protective services” to older adults arose in the 1960s. The 1961 White House
Conference on Aging (Anetzberger, 2011; National Council on Aging, 1963) formally
recommended synergizing social, medical, and legal services in efforts to support older
Americans in need of “social protection” (White House Conference on Aging, 1961). The first
case review EA MDTs were launched in the early 1970s (Anetzberger, 2011). The term “case
review” refers to teams that address individual elder abuse cases. Although non-case review EA
MDTs exist, the interest of current elder abuse policy and research lies almost exclusively in case
review MDTs and will therefore be the focus of this dissertation (Connolly, 2010). Case review
MDTs will be referred to as “EA MDTs” or “MDTs”.
An early survey of EA MDTs identified 32 unique programs in the United States (Teaster
et al., 2005). EA MDTs vary in terms of auspices, legal foundation, structure, and focus
(Anetzberger, 2011; Breckman, 2015). First, there is variation in the supporting organization or
entity. For example, MDTs can be part of healthcare organizations, legal entities, or extensions
of Adult Protective Services. Additionally, MDTs differ in legal basis. Some are mandated by
4
state legislation, while others are formed organically through interagency collaboration or a
single organization’s initiative (Anetzberger, 2011; Breckman, 2015). Formality of membership
also varies between MDTs, ranging from an informal group meeting to a contractual agreement
between members and the MDT. MDTs can also vary in terms of abuse orientation. Some teams,
such as Financial Abuse Specialist Teams (FASTs), focus on one type of abuse; others address
multiple types of abuse. There is also variation in terms of task level: some only review death
cases (Fatality Review Teams), some provide medical/mental assessment (Vulnerable Adult
Specialist Teams), others make use of forensic accounting and specialized case management
(service advocates) (Anetzberger, 2011; Breckman, 2015 Navarro, 2011; Teaster et al., 2005;
Twomey, 2010).
Most of the perceived benefits and characteristics of successful MDTs have been based
on limited qualitative data, surveying a limited number of MDT key informants (Teaster et al.,
2005). Despite limitations in available data, the perceptions of MDTs have been generally
positive. MDTs have been identified as providing holistic case assessment and solutions for elder
abuse cases, leading to efficient case resolution and decreased APS recurrence (Anetzberger,
2011; Breckman, 2015). Relatedly, MDTs have been noted to improve awareness and education
among members, increase access to case information, and help clarify agency/member roles to
reduce the duplication of efforts on cases (Anetzberger, 2011; Breckman, 2015; Teaster et al.,
2005).
Major priorities in MDT research include measuring and evaluating the effectiveness and
success of this intervention (Teaster et al., 2005; Yonashiro-Cho et al, 2019). Studies designed to
understand MDT processes and characteristics associated with effectiveness have identified
strong leadership and skilled meeting facilitation as core elements of a successful MDT
5
functioning and outcomes (Anetzberger, 2011; Twomey, 2010). Given that MDTs are interaction
platforms for multiple disciplines—each with their own methodologies and value systems—
understanding how to facilitate cooperation and maximize the strength of each discipline are key
components of achieving case goals (Anetzberger, 2011; Twomey, 2010). Belief in
collaboration, valuing input, accountability, and honesty have also been identified as key
elements of successful functioning and outcomes (Twomey, 2010). Although strong
infrastructure has been identified as an element of success, this infrastructure can vary depending
on an MDT’s team composition, geographic location, and resource needs (Twomey, 2010).
In addition to perceived benefits and success, several challenges have been identified
through qualitative research. One set of challenges relates to the collaboration of multiple
disciplines: group dynamics, lack of trust between members, lack of participation, and
dissonance in purpose or goals (Anetzberger, 2011; Twomey, 2010). More research is needed to
understand ways to manage these challenges in the context of teams across the United States, and
to develop strategies to overcome communications and interagency relationship barriers. A
second set of challenges relates to administrative burden: MDT budget sustainability, securing
adequate administrative support, and how to ensure a stable number of cases referred to the team
(Anetzberger, 2011; Twomey, 2010).
Although the field is new and knowledge on EA MDTs contains gaps, there is a
foundation of qualitative information and conceptual developments to support future research on
EA MDTs. Within this foundation, several gaps in the literature can be identified. First, most
research on EA MDTs relies on small purposeful samples. These studies lack the statistical
power to make inferences about EA MDTs and develop evidence-based recommendations for
improvement and establishment. A better understanding of the prevalence and types of EA
6
MDTs across the country is needed, including building evidence to support the benefits and
challenges identified in the literature. Second, variations across EA MDTs make it difficult to
secure support from policymakers and from the public in general. A better understanding of
common characteristics across teams is needed to make communications about this model more
understandable. Third, the literature on EA MDTs gathers data primarily from team leaders or
coordinators, leaving a major resource for knowledge untouched: team members. A better
understanding of team members’ backgrounds, challenges, contributions, and motivations should
result in more effective efforts to recruit new members and address the needs of current
members.
The Elder Abuse Forensic Center: A Promising Standard for MDTs
An emerging body of research on EA MDTs is related to one specific case review MDT
model that originated in California: the Elder Abuse Forensic Center (EAFC). This model was
developed in Irvine, CA in 2003, with the intention of forming a high-powered, formally staffed
(dedicated program positions), regularly-convened MDT that performs case review, provides
case recommendations, and provides direct services as-needed (Gassoumis, Navarro, & Wilber,
2015; Schneider, Mosqueda, Falk, & Huba, 2010). These direct services included medical
assessment, functional assessment, cognitive assessment, evidence-building, and documentation
review with an emphasis on evidence-based practices and methods (Schneider, Mosqueda, Falk,
& Huba, 2010; Wilber et al., 2013). Elder abuse initiatives from a California foundation (the
Archstone Foundation in Long Beach, CA) led to the replication of this model in Los Angeles,
San Francisco, and San Diego. Similar MDTs have been developed across the country,
sometimes using different names (i.e., “Enhanced” MDTs in New York). On a national level,
7
EAFC research and replication has been identified as a priority in federal policy through the
Elder Justice Act of 2010.
Research on the effectiveness of EAFCs is limited, but promising. A team survey of the
EAFC in Los Angeles indicated several positive themes: frequent meetings, collaboration
opportunities, availability of information, coordinated information, and access to clinicians
(Navarro et al., 2010). Cases brought to an EAFC have been shown to significantly increase rates
of submission for prosecution compared to traditional interventions (Adult Protective Services)
(Navarro, 2013). Additionally, cases brought to an EAFC were nearly seven times more likely to
be referred for conservatorship (Gassoumis, 2015). It should be noted that while these metrics
are useful for understanding the outputs of EAFCs, they do not provide evidence supporting
whether EAFCs are effective or successful in resolving elder abuse cases. Nevertheless, the
EAFC model offers a promising elder abuse intervention and receives positive feedback from
frontline workers (Elder Justice Act, 2010; Schneider et al., 2010; Navarro et al., 2010). Given
the high promise of EAFCs as a standard for MDT replication, this dissertation will use the
EAFC model as a guiding framework to better understand EA MDTs across the U.S.
EAFC Model Description
The EAFC conceptual model has undergone several iterations, continually informed by
observations of several of the early operating sites. Most recently, Yonashiro-Choi et al. (2019)
used qualitative methods to study the four EAFC sites in California to identify common
components and practices for model clarity. In this model, shown in Figure 1.1, three
professional areas are in collaboration: client services, direct service providers, and justice
systems. Relatedly, previous research identified core membership (APS, Medical Personnel,
Prosecuting Attorney, Victim Advocate, Law Enforcement, Public Guardian / Conservator),
8
common membership (LTC Ombudsman, Gero/Neuro-psychologist, Mental Health Services,
Senior Legal Aid), and occasional membership (Developmental Disability Services, Coroner /
Medical Examiner, Community Care Licensing, Intimate Partner Violence Services) (Wilber et
al., 2013). These disciplines engage in a “forensic process” that involves team activities: case
review, consultation, documentation, training, and team building. This process also involves the
utilization and provision of resources: program coordination, geriatric physical and mental
healthcare, and activities performed by team members outside of normal meetings times. This
forensic process takes place within a structural environment that can vary in terms of meeting
space, methods of communication (video and teleconferencing), information sharing, and
relationship formalization. A figure of the model can be found below:
9

10
Summary Overview of the Dissertation
Elder abuse and mistreatment are urgent and persistent issues that prevent older adults
from living healthy and secure lives (Acierno et al., 2010; Lachs et al., 1997). The wide range of
abuse types and complicated contexts of abuse create a unique challenge for professions
involved in addressing it. The Elder Abuse Multidisciplinary Team provides a platform for these
professions to collaborate on cases and has been identified as a promising intervention for elder
abuse (Connolly, 2010). Research is needed to further understand this intervention in the United
States, to facilitate policy support, improvements to existing teams, and establishment efforts
nationwide.
The following chapters of this dissertation included three distinct papers and a concluding
chapter that synthesizes and summarizes the results. Each chapter addresses a gap in the MDT
literature, using the EAFC as a guiding theoretical framework and applying the findings to the
relevant components of the framework. This dissertation aims to contribute to the field by adding
to the knowledge of EA MDT functioning and implementation and offering a useful evidence
base for the replication and improvement of MDTs nationwide. The first aim of this dissertation
is to illustrate the national landscape and scope of MDTs (Chapter II). A second aim of this
dissertation is to contextualize the EAFC model, to amplify its applicability for MDT replication
and establishment (Chapter III). The third aim of this dissertation is to provide information from
the perspective of team members, to inform recruitment and improvements in MDT functioning
(Chapter IV) Toward these goals, this dissertation will use primary data collected from EA MDT
affiliates (Chapter II), coordinators (Chapter III), and members (Chapter IV) across the United
States. The instruments used to collect this data were guided by the EAFC Conceptual
11
Framework and validated by a panel of elder abuse experts from a variety of professional
disciplines.
Chapter II reports on national prevalence of EA MDTs across the U.S. and explores
respondents’ perspectives and attitudes toward EA MDTs. A key research priority is the
adequate representation of teams nationally (Yonashiro-Cho et al., 2019). Previous literature has
provided this information, but data were limited to approximately 30 teams (Teaster et al., 2005).
The EAFC conceptual model is applied in this chapter to form survey questions that capture
geographic, MDT structure, MDT function, and individuals’ perspectives on EA MDTs. More
substantive data collection will provide a stronger case for the value of this intervention. Data
collection for this chapter took place in the Summer of 2017.
Chapter III uses Latent Class Analysis to classify EA MDTs. In Yonashiro-Cho et al.’s
analysis, only three of the four EAFCs identified as Forensic Centers at the conclusion of the
study (2019). While all four sites were formed under the “Forensic Center” initiative, one site
chose to adopt a “client-empowerment” model (in which clients could select and patron
services), and therefore no longer self-identified as an EAFC (Yonashiro-Cho et al., 2019). The
remaining three sites were similar in “programmatic philosophies, structures, and operational
approaches” (Yonashiro-Cho et al., 2019). A key research priority was identified to “refine
program fidelity markers” (Yonashiro-Cho et al., 2019). In this chapter, the updated EAFC
Conceptual Model is used to create classes of EA MDTs in the United States, to determine the
extent to which this model has been adopted or independently initiated. Data collection for this
chapter took place in the Spring of 2018.
Chapter IV of this dissertation will provide novel descriptive statistics on an understudied
population in EA MDT research: team members. Understanding team member perspectives
12
could provide valuable evidence for the recruitment of new MDT participants, and could shed
light on benefits and challenges of EA MDTs that may have been overlooked. Previous studies
have included some team member feedback on their experiences on EA MDTs (namely, EAFC
qualitative site visit research), but this data does not provide a clear picture of a team member’s
experience on a team. In this chapter, the EAFC conceptual model is applied to create survey
questions about the motivations of MDT members, the process of MDT case review, and impacts
of the MDT on members. This chapter reports on MDT member characteristics, perceptions of
the MDT case review process, perceptions of success, and perspectives on the MDT creation
process. Data collection for this chapter took place in the Fall of 2019.
The conclusion of this dissertation provides an overview of findings and applications of
this research to build the field. These findings can be used to inform policymakers, practitioners,
academics, and the general public on EA MDTs. This chapter also provides an implementation
science framework to clarify the role of these findings in assisting MDT and EAFC
implementation efforts.

13
CHAPTER 2: A NATIONAL DESCRIPTIVE STUDY OF ELDER ABUSE
MULTIDISCIPLINARY TEAMS IN THE U.S.
Introduction
Elder abuse (EA) is a serious public health issue that affects 1 in 10 older adults in the
United States (Acierno et al., 2010). EA is defined as “intentional actions that cause harm or
create serious risk of harm, whether or not intended, to a vulnerable elder by a caregiver or other
person who stands in a trust relationship to the elder” (Bonnie & Wallace, 2003) Elder abuse is
often categorized into five distinct types: physical abuse, psychological abuse, sexual assault,
financial exploitation, and neglect (Council, 2013; Lachs et al., 1997; Pillemer, 2016). A related
phenomenon of elder self-neglect is considered distinct from EA but is often included in elder
abuse discussion and literature. Self-neglect is defined as the “refusal or failure to provide
oneself with care and protection in areas of food, water, clothing, hygiene, medication, living
environments, and safety precautions” (Dong, 2017). Elder abuse and self-neglect are associated
with poor health outcomes and increased risk of death for older adults.
EA is difficult to identify, address, and resolve. Investigation of EA cases may require
review of legal and financial documents, or a clinical assessment of the victim’s cognitive
capacity (Navarro et al., 2010). Resolution of EA cases can be hindered by several factors,
including history of abuse, polyvictimization, and mental illness or substance abuse in
perpetrators and/or victims (GAO, 2010; Ramsey-Klawsnick et al., 2016). Given the complexity
of elder abuse resolution, multidisciplinary approaches are sometimes necessary to coordinate
investigations, consult experts, and utilize services.
Multidisciplinary teams (MDTs) bring together legal, social services, and medical
professionals to collaborate and deliberate on appropriate courses of action on EA cases. Teams
14
vary in auspice, legal basis (mandatory or optional), formality of membership, abuse focus, and
intensity of tasks (Anetzberger, 2011; Breckman, 2015). Additionally, the conception and
creation of each MDT varies depending on needs of agencies and the population. For example,
Financial Abuse Specialist Teams (FASTs) were developed in response to the need for APS
(Adult Protective Services) and law enforcement to effectively navigate complex financial
exploitation cases (Twomey et al., 2010). Relatedly, Assessment Teams are MDTs that are
focused on the delivery of medical and psychological geriatric assessment, specifically evolved
from MDTs that noted a lack of medical and psychological expertise. Qualitative research
suggests substantial variation between MDTs in the U.S., an idea that has not been explored
using comprehensive survey data (Twomey et al, 2010).
The literature on EA MDTs supports the idea that MDTs enhance teamwork across
traditionally siloed systems and increase prosecution (Navarro et al., 2010; Navarro et al., 2013).
The multidisciplinary approach to elder abuse can be traced to concepts of “protective care” for
older adults in the 1950s, which led to recommendations for a “constellation of services,
preventative or supportive in nature” to preserve the well-being of older adults (Anetzberger,
2011; National Council on Aging, 1963). More concrete support of multidisciplinary teams was
shown at the first White House Conference on Aging in 1961, which recognized that “the
professions of social work, medicine, and law should make their services available to older
persons who are in need of social protection […] in such a way that they are mutually
supportive” (White House Conference on Aging, 1961). Evidence of Elder Abuse MDTs
conducting elder abuse case diagnosis and action plans appeared in 1971 (Anetzberger, 2011).
These Elder Abuse MDTs that review and address individual cases of elder abuse, with a goal of
providing specific recommendations are considered case review Elder Abuse MDTs.. Despite
15
limited quantitative data, there is strong anecdotal support from leaders in the EA field for the
use of MDTs to address EA cases, particularly regarding the Elder Abuse Forensic Center
(EAFC) Model (Mosqueda, 2012).
The EAFC Model uses dedicated staff to convene regularly-scheduled, face-to-face
meetings among diverse professionals from health, legal, and social services to collaborate and
determine action steps following EA case review (Navarro et al., 2010; Navarro et al., 2013;
Gassoumis et al., 2015; Yonashiro-Cho et al., 2019). Federal policy through the Elder Justice Act
has prioritized the replication of EAFCs nationwide as part of efforts to improve capacity to
effectively address EA (Elder Justice Act [EJA], 2010). Although the EAFC model has been
replicated in other sites, more research is needed to quantify the number of EAFCs in the U.S.
and understand variations in this model. Furthermore, existing EAFC research has been used to
depict a general structure for this model, which was used in the conceptual framework and
process of this study.

16
Conceptual Framework
This study is the first in a series of related studies aiming to further understand the
structures and components of the Elder Abuse Forensic Center Model. Therefore, we used the
EAFC conceptual model to create survey questions (Gassoumis et al., 2015; Yonashiro-Cho et
al., 2019). Originally developed by Navarro et al. (2010) based on the Los Angeles EAFC, this
conceptual model has been honed over time (see Gassoumis et al., 2015; Yonashiro-Cho et al.,
2019).
The Elder Abuse Forensic Center conceptual model contains several components,
including a supportive infrastructure (e.g., meeting/office facilities, information sharing, and
tele/videoconferencing). At the top of the model are the investigators and direct service
providers—which include APS, law enforcement, aging networks, public guardian, and mental
health services. These individuals are “often the lynchpin in managing the various components of
elder abuse cases” (Gassoumis et al., 2014). Investigators and direct service providers are linked
to both client services (APS, Public Guardian, Long-term Care Ombudsman) and justice systems
(law enforcement, prosecutor’s office, legal assistance, victim advocate).
These three components (investigators, client services, justice systems) work together in
a “Forensic Process” that involve a variety of activities and resources. Activities include case
acquisition, case review/real-time decision-making, mental health and physical health
consultations/assessments, documentation, training, outreach, and team building. Accomplishing
these activities requires specific resources, which have been identified as a program coordinator,
a geriatrician, a gero/neuro-psychologist, and team members who can provide input and carry out
tasks beyond the meeting time (during the “other 38 hours”). The “other 38 hours” refers to time
17
team members spend working on the case outside of the EAFC meeting, which helps build trust
and rapport (Yonashiro-Cho et al., 2019).
The Forensic Process is designed to enhance service provision and is thought to
accomplish three types of outcomes. First, there are a set of outcomes specific to the older
victim: improved client safety, protection of client assets, and enhanced access to criminal and
civil justice. Second, outcomes for professionals involved include improved interagency
communication and collaboration, increased knowledge about mistreatment, and increased
knowledge about resources available to vulnerable older adults. Third, anticipated outcomes for
the community are abuse prevention and increased knowledge.
18

In this paper, we use the Elder Abuse Forensic Center conceptual model as a lens for
evaluating MDTs across the U.S. This model guides the drafting of survey questions, selection of
19
analyses, and interpretation of results. Because this MDT model holds promise among
researchers and EA professionals, in addition to policy support from the Elder Justice Act of
2010, this framework will be used to provide context to additional EAFC research, and help in
efforts to replicate this model nationwide.
Developing a better understanding of the promising EAFC MDT model first requires
filling several gaps in knowledge. First, little is known about the number and location of most
EA MDTs in the U.S. A national survey conducted over fifteen years ago identified and studied
32 MDTs in the U.S. (Teaster et al., 2003), providing a useful starting point to understand the
growth and innovation in MDTs that developed since. Second, despite strong anecdotal support
for EAFCs from EA professionals, little is known about general perceptions of MDT
effectiveness. Qualitative research has identified perceived benefits of MDTs: decreased
recurrence, holistic approaches, and improved awareness/education of team members
(Anetzberger, 2011; Breckman, Callahan, & Solomon, 2015). Studies have shown increased
prosecution and conservatorship from the EAFC model, but these findings are limited to one
EAFC in Los Angeles, California (Gassoumis, Navarro, & Wilber, 2015). Third, little is known
about basic characteristics of EA MDTs, including type of abuse addressed by the MDT. This
descriptive study on the current national infrastructure of MDTs surveys elder abuse
professionals nationwide to fill these gaps, and build a foundation for cross-site analyses,
assessment of effective MDT models, and replication of MDTs across the country.
Design and Methods
Data Collection
An online survey was sent through a Qualtrics link to U.S. individuals involved in elder
abuse efforts. This link allowed respondents to remain anonymous. Contact information for these
20
individuals was gathered from various listservs from the USC Secure Old Age Lab and the
National Center on Elder Abuse. The first wave of recipients had the ability to forward the
survey link to other individuals working in elder abuse that they thought might have been able to
contribute MDT information. The objective of this dissemination was to reach and survey as
many elder abuse professionals and affiliates nationwide who might have information on EA
MDTs. 524 respondents were recorded for this survey. Respondents were given the option to
skip any question on the survey. Thus, n values for various survey items may differ.
For the development of the items and the overall content, this survey was presented at a
convening of a diverse panel of elder abuse experts that provided revisions and approval of
survey questions, based on their significant experience in the elder abuse field. The expert panel
included law enforcement, legal professionals, social workers, multidisciplinary team
coordinators, academics, and physicians. Concepts from the Delphi process were used to reach
consensus on survey questions (Dalkey & Helmer-Hirschberg, 1962).
Survey Items
Items in the survey captured information about respondents and the MDTs they
identified. Definitions of key terms were given to respondents.
Elder Abuse was defined as “abuse, neglect, or financial exploitation of an elder. The
abuse could be physical abuse, or psychological/emotional/verbal/mental abuse. Other related
phenomena (such as self-neglect) may be considered elder abuse in some areas based on legal
definitions.”
Elder Abuse Multidisciplinary Team (MDT) was defined as “a team comprised of
professionals from a variety of disciplines working together on an ongoing basis to combat elder
abuse.”
21
Case Review was defined as “reviewing and addressing individual cases of elder abuse,
with a goal of providing action steps and recommendations specific to that case.”
Respondent organization/agency. Respondents were asked about the organization or
agency they worked for. This included Adult Protective Services (APS), law enforcement, legal
services, healthcare, social services (other than APS), clergy, governmental services, and other
organization or agency. For the “governmental services” and “other” response choices, a free
response text box was given. Categories for this survey item were created based on the expert
panel and the researchers’ own experience with elder abuse MDTs.
Respondent state. Respondents were asked to identify the primary state in which they
perform their professional duties. The response options included all 50 United States, in addition
to Puerto Rico and Washington, D.C. Respondents were given the option of identifying
additional states in a subsequent question.
Respondent elder abuse experience. Respondents were asked the amount of time they
have worked on elder abuse issues. Responses were categorized as “11+ years”, “6-10 years”,
“2-5 years” and “less than 1 year.
Respondent can identify MDTs. Respondents were asked if they were aware of EA
MDTs in their area that engage in case review. Given that the purpose of this study is to build
context for the EAFC MDT model, which is a case review model, this item focused exclusively
on case review MDTs. The respondents who responded “yes” to this item were then asked to
manually identify the name of each MDT they knew. The respondents then answered a set of
questions for each identified MDT.
Respondent attendance. Respondents were asked if they have ever attended a meeting
of each MDT they identified. Respondents were also asked to describe their attendance at each
22
MDT they identified, categorized as “once”, rarely, occasionally, frequently”. Additionally,
respondents were asked the last time they attended a meeting at each of the MDTs they
identified, categorized as “within the last year”, “1-3 years ago”, and “more than 3 years ago”.
Respondents were asked if they have been invited to attend a meeting of the MDT, in addition to
their reason for not attending, if applicable.
Respondent role and MDT impact. Respondents were asked their primary role in each
MDT they identified, categorized as “observer”, “team member”, “presenter”, and
“coordinator/administrator/facilitator”. “Observers” are individuals who attend and observe team
meetings, but do not give substantive input or suggestions on cases. Respondents were also asked
about how their participation in the MDT has changed how they address elder abuse cases,
categorized as “not at all”, “a little”, “somewhat”, and “a great deal”.
Respondent perception of MDT. Respondents were asked about their perception of
each identified MDT’s impact on EA case outcomes, recurrence, and overall occurrence of EA in
their community. For these three measures, respondents were given a 5-point Likert scale from
“very negatively” to “very positively. Respondents were also asked to identify the most valuable
aspects of meetings at the MDT, which included “educational presentations”, “follow-up on
previously presented cases”, “networking”, “new case presentation/discussion”, and “program
development/planning”
MDT housed within host agency/healthcare. Respondents were asked whether each
MDT identified is housed within or affiliated with a host organization/agency. Respondents were
also asked if each MDT operates within a hospital or healthcare system, in any capacity.
MDT type of EA. Respondents were asked to select, to the best of their knowledge, the
types of abuse and related activities addressed by each MDT they identified. This included the
23
five standard EA types (physical, psychological, financial, neglect, sexual), self-neglect,
hoarding, death review, and a free response “other” category.
Analysis
Unique IDs were created for each MDT identified by survey respondents. This was
accomplished by sorting MDTs by state, identified key informant, and alphabetical order in
Microsoft Excel. Since the unit of analysis was the MDT itself, MDTs that appeared to have
duplicate or multiple entries from multiple respondents were reviewed and removed from the
spreadsheet.
Weights were used on both person-level (questions involving the respondent’s
perceptions or views) and MDT-level responses (questions involving the single or multiple
MDTs the respondent identified) to prevent overrepresentation of MDTs that were reported
multiple times (Porter, 1973). Person-level weights were calculated as 1/number of survey
respondents, meaning every respondent was counted once. MDT-level weights were calculated
as 1/number of unique MDTs, meaning every MDT was counted once. MDT-person level survey
items were not weighted, meaning every respondent’s answer about an MDT was counted once.
Due to this weighting technique, some frequencies will be shown as decimals. For ease of
interpretation, the reader should primarily refer to percentages when reading results. Univariate
frequencies for each item were calculated using SAS 9.4. Bivariate statistics were used to
explore differences in perceptions based on number of abuse types addressed by the MDT,
occupation of the respondent, whether the MDT was affiliated with a healthcare system, and how
involved the respondent was in the MDT.

24
Results
Respondent Characteristics
Over one third (36.6%) of respondents indicated they work for APS, and one sixth
(15.8%) indicated they work for “other governmental agency”. The “other governmental agency”
free response included a Medicaid fraud control unit, state aging agencies, tribal organizations,
and local government health/adult services agencies. Thirteen percent (13.2%) of respondents
selected the “other” category, which included higher education, food banks, dementia coaches,
retired nurses, advocates, and non-profit organizations. Ten percent (10.39%) work for a social
services agency other than APS, 6.6% work for a district attorney, 6.6% work for legal services,
and 5% work for healthcare. Less than 3% of respondents work for a financial institution, family
violence, or law enforcement.
In terms of length of time working on elder abuse issues, approximately half (48.8%) of
respondents indicated they have worked on elder abuse issues for over 11 years. 22.4% of
respondents have been working on elder abuse issues for 6-10 years, and 22.4% of respondents
have working on elder abuse issues for 2-5 years. 6.24% of respondents have been working on
elder abuse issues for less than 1 year.
The majority (86.8%) of respondents indicated that they were aware of EA MDTs in their
area. Of those respondents, 80.1% indicated that they had attended a meeting at each of the
MDTs they identified. Differences in n values result from respondents who identified multiple
MDTs and/or chose to skip various questions. Of those who attended a meeting at the MDT,
71.3% indicated that they attend frequently, 17.3% attend occasionally, 5.8% attend rarely, and
5.5% attend once. Additionally, most (82.3%) respondents had attended the MDT within the last
year. Regarding respondents’ role in the MDT, the majority (58%) indicated that they participate
25
as a team member. 32% were coordinators/administrators/facilitators, 20% were presenters, and
14% were observers.
The 20% of respondents who have not attended a meeting at their MDT were asked if
they were invited to attend, and their reason for not attending. 8 respondents (11%) indicated
they had been asked to attend. In terms of reason for not attending, 14% selected “not a good use
of time”, and 8% selected “willing, but too busy”. The majority (70%) of respondents selected
the “other” category. In the “other” category, 15 respondents cited distance and jurisdiction
restrictions as the reason for not attending.
26

Table 2.1. Characteristics of Respondents Involved in Elder Abuse
Item Frequency Percent
Profession
APS 110 36.3
District Attorney 20 6.6
Family Violence 6 1.98
Financial Institution 4 1.32
Healthcare 15 4.95
Law Enforcement 7 2.31
Legal Services 20 6.6
Social Services Agency (not APS) 33 10.89
Other Governmental Agency 48 15.84
Other (please specify) 40 13.2
Missing --
Length of Time in Elder Abuse
11+ years 148 48.84
2-5 years 68 22.44
6-10 years 68 22.44
Less than 1 year 19 6.27
Missing --
Primary Role in Meetings
Observer 46 14.11
Team Member 189 57.98
Presenter 61 18.71
Coordinator/Adminstrator/Facilitator 103 31.6
Missing 443
Aware of MDTs in Area
Yes 263 86.8
No 40 13.2
Missing --
Has Attended MDT Meeting
Yes 338 80.09
No 84 19.91
Missing 347
Description of Attendance
Attend frequently 234 71.34
Attend occasionally 57 17.38
Attend rarely 19 5.79
Attended once 18 5.49
Missing 10
Has Been Asked to Attend a Meeting
Yes 8 10.96
No 65 89.04
Missing 11
Reason for Not Attending
Hostile/disagreeable relationships 2 4
Willing but too busy 4 8
Organization/employer does not provide time 2 4
Not a good use of time 7 14
Other (please specify) 35 70
Missing 34
27
MDT Information
324 unique MDTs were identified. Respondents identified the primary state for each EA
MDT. A map of the United States illustrates the distribution of MDTs. The states with the most
MDTs included California (68), Wisconsin (42), Minnesota (31), New York (30), and Michigan
(17). No MDTs were identified in Idaho, New Mexico, South Dakota, Nebraska, Arkansas,
Louisiana, Mississippi, Indiana, Kentucky, and New Jersey.
77% of MDTs were identified as being housed within a host organization or agency.
Relatedly, 50% of MDTs were identified as operating between a hospital or healthcare system.
MDTs that were identified as being housed within a host organization or agency were positively
and significantly correlated with MDTs identified as being part of a hospital or healthcare system
(x
2
= 57.84, p<.001).
In terms of type of abuse, 90% of teams were identified as addressing financial
exploitation, followed by physical abuse (85%), neglect by other (82%), psychological/emotional
abuse (80%), sexual abuse (77%), self-neglect (72%), hoarding (61%), death (31%), and other
(11%). The “other” category free response was primarily used by respondents to elaborate on the
abuse types selected. Some respondents used the free response option to specify other issues
addressed by the MDT, such as guardianship or elder abuse education. Most teams (71%) were
identified as addressing six or more types of abuse, and 10% of teams addressed only one.
28

29

Table 2.2. MDT Characteristics
Item Frequency Percent
MDT Housed within a Host Agency
Yes (please specify) 212.07 77.12
No 29.42 10.7
Unknown 33.52 12.19
Missing 298.99
MDT Operates within a Healthcare Organization
Yes 135.68 49.73
No 84.40 30.93
Unknown 52.76 19.34
Missing 301.16
Type of Abuse Addressed
Physical 229.67 84.61
Sexual 208.12 76.67
Psychological 215.19 79.27
Financial 244.81 90.18
Neglect 223.46 82.32
Self-neglect 195.85 72.15
Hoarding 164.75 60.69
Death 84.80 31.24
Other 30.28 11.16
Missing 302.54
Number of Abuse Types Addressed
1 27.42 10.1
2 10.50 3.87
3 10.55 3.89
4 10.57 3.89
5 18.98 6.99
6 41.78 15.39
7 84.31 31.06
8 67.36 24.82
Missing 302.54
Number of Abuse Types Addressed (APS Consensus Guidelines)*
1 21.06 7.76
2 5.97 2.2
3 12.70 4.68
4 14.07 5.18
5 38.29 14.11
6 166.38 61.29
Missing 302.54
*Defined as "physical, emotional, sexual abuse; financial
exploitation, neglect; and self neglect."
30
Perception of MDTs
Respondents were asked various questions regarding their perception of identified MDTs.
Approximately half (49%) of respondents indicated that participation in MDTs has changed the
way they approach EA cases “a great deal”. 30% selected that MDT participation has changed
their approach “somewhat”, 14% selected “a little”, and 7% selected “not at all”. When asked
about the most valuable aspects of MDT meetings, the most common responses were “new case
presentation/discussion” (41%) and “networking” (35%), followed by “educational
presentations” (10%), “program development/planning” (7%), and “follow-up on previously-
presented cases” (7%). Funding/resources (37%), time commitment (35%), member engagement
(23%), agency engagement (24%) were most commonly identified as barriers
When asked how their identified MDT changes outcomes for its elder abuse cases, 28%
selected “very positively”, 57% selected “positively”, and 14% remained neutral. Regarding their
identified MDT’s impact on EA recurrence, 12% or respondents selected “very positively”, 44%
selected “positively”, and 42% remained neutral. When asked about their identified MDT’s
impact on overall EA occurrence in their community, 15% of respondents selected “very
positively, 42% selected “positively”, and 42% remained neutral. Less than 2% of respondents
selected “negatively” or “very negatively” regarding outcomes, recurrence, and overall
occurrence questions.
31

Table 2.3. Perceptions of MDTs
Item Frequency Percent
MDT Changes Outcomes for Elder Abuse Cases
Very positively 59.37 27.52
Positively 121.99 56.55
Neutral 30.30 14.05
Negatively 0.05 0.02
Very negatively 4.00 1.85
Missing 358.28
MDT Impacts Recurrence/Recidivism of its Elder Abuse Cases
Very positively 25.84 12.04
Positively 94.34 43.96
Neutral 91.37 42.58
Negatively 0.05 0.02
Very negatively 3.00 1.40
Missing 357.48
MDT Impacts Overall Occurrence of Elder Abuse In the Community
Very positively 31.95 14.75
Positively 90.27 41.69
Neutral 91.25 42.14
Negatively 0.05 0.02
Very negatively 3.00 1.39
Missing 357.48
32

Discussion and Implications
Discussion
Building on existing EAFC literature, we surveyed 524 elder abuse affiliates nationwide
to give a better understanding of the number of EA MDTs in the U.S. and how they are
perceived by individuals in the field. The purpose of this study was to illustrate the landscape of
EA MDTs in the U.S., and to create a foundation for further exploration of the EAFC model.
Most respondents in this study were long-time workers in the elder abuse field (half for
11+ years)—largely from Adult Protective Services and social services—who took on roles as
team members and/or coordinators. Respondents were aware of at least one MDT in their area
Table 2.4. Perceptions of MDTs (cont.)
Item Frequency Percent
MDT Participation has Changed Respondents' Approach to Elder Abuse Cases
A great deal 77.10 49.04
Somewhat 47.22 30.03
A little 22.34 14.21
Not at all 10.57 6.72
Missing 145.77
Most Valuble Aspects of MDT Meeting
Educational presentations 33.00 10.22
Follow-up on previously presented cases 22.00 6.81
Networking 113.00 34.98
New case presentation/discussion 131.00 40.56
Program development/planning 24.00 7.43
Missing 15.00
Barriers to MDT Success/Improvement
Funding/resources 81.45 37.38
Team organization 25.15 11.54
Team leadership 14.07 6.46
Time commitment 75.30 34.56
Transportation to MDT meeting 1.71 0.79
Difficulty identifying cases for review 37.81 17.35
Member engagement 51.01 23.41
Agency engagement 52.47 24.08
Percieved inability to share information 32.47 14.90
Hostile/disagreeable relationships between MDT members 4.36 2.00
MDT members can be intimidating 2.80 1.28
Other 26.24 12.04
No major barriers 41.84 19.20
Missing 356.08
33
and were frequent participants in the MDTs they identified. Furthermore, respondents who did
not participate in meetings cited distance as a main limiting factor.
Most MDTs identified were housed within a host agency, and half operate within a
healthcare organization. Additionally, most abuse types were identified as addressed by the
MDTs. Although 70% addressed more than six types of abuse, slightly fewer (60%) addressed
all six types outlined in the APS consensus guidelines. Furthermore, approximately 1 in 10
MDTs focused on only one type of abuse.
MDTs were shown to be perceived positively in terms of outcomes, reducing recurrence,
and occurrence of elder abuse in the community. Respondents also endorsed that participation in
MDTs was also shown to have changed their approach to elder abuse cases. The presentation of
new cases and the opportunity to build a network were identified as the most valuable aspects of
MDT meetings. Funding, agency engagement, and time commitments were the most common
barriers to MDT success and improvement.
Elder Abuse MDTs in the U.S.: A Trove of Knowledge
The findings of this study provide potentially valuable information to individuals or
organizations seeking to form new teams or improve upon existing teams. An unprecedented and
unexpectedly high number of teams were identified in this study compared to the number
identified more than a decade and a half earlier Teaster et al., 2003. These findings suggest that
the EA MDT is a widely utilized tool that has taken root across the U.S. and is utilized by a
variety of professionals who interface with older adults. Several states have passed legislation
related to elder abuse interventions (CA, MN, WI), and our results showed a high number of EA
MDTs in these states. Whether organically developed or policy driven, the need for an MDT in
an area must be assessed prior to moving forward with implementation. For example, an
34
unfunded MDT mandate may result in a team that exists only to fulfill legislative requirements,
not the needs of the community, and ultimately may have less impact on elder abuse occurrence,
recurrence, or outcomes. This is a particularly important consideration given that funding and
resources were identified as primary barriers to MDT success and improvement. Individuals or
organizations seeking to form or improve EA MDTs should prioritize funding and member
engagement (funding source and amount of funding for MDTs will be captured in a subsequent
survey).
Additionally, approximately three-fourths of MDTs were housed within a host agency.
This characteristic suggests that individuals seeking to start an EA MDT should consider host
organization that can provide support (e.g., a meeting place, visibility/legitimacy, staff, team
members). Conversely, organizations with or without the capacity to initiate and sustain an MDT
should explore opportunities to support individuals seeking to participate. Since a large
proportion of EA MDTs are initiated and sustained by APS workers, this also highlights the
importance of bridging social, health, and justice services. Although many MDTs were described
as located within a healthcare organization, over one-third of survey respondents/MDT
participants work for APS. This contrast suggests that elder MDTs may serve as a hub for
linking health and social services that traditionally would have been siloed. Additionally, this
linkage could help improve the member/agency engagement and time commitment barriers to
MDT success/improvement, as professionals are given more opportunities to recognize the
importance of a multidisciplinary approach. Healthcare organizations seeking to improve their
response to elder abuse should consider housing, or at the very least participating in an MDT.
The Elder Abuse Forensic Center Model
35
These findings provide a useful foundation and context for EAFC model improvement
and exploration moving forward. Yonashiro-Cho et al. expanded on the EAFC model by adding
an additional outcome of enhanced service provision: benefits to professionals in the elder abuse
field (2019). The findings in the current study support this addition, showing that elder abuse
professionals are impacted positively by their involvement in EA MDTs. Findings also support
the idea of impact on vulnerable adults in terms of outcomes, and impact on community in terms
of prevention.
Findings suggest that aspects of the components seen in the EAFC model—client
services, investigators/direct service providers, and justice systems—exist in MDTs across the
country. More research is needed to determine the nuances of which MDTs might fit this model
and what additional characteristics they include. Future research should continue working to
confirm or modify specific characteristics of MDTs, including comparing different types of
MDTs and working to measure outcomes to build evidence of effectiveness. In addition, it is
important to continue in-depth analysis of EAFCs using both quantitative and qualitative
approaches.
Limitations
This survey asked respondents for their assessment of how their MDT impacted elder
abuse occurrence, recurrence, and outcomes. Future research should conduct formal program
evaluations of MDTs to gain a better understanding of model effectiveness. Additionally, data
were gathered from elder abuse affiliates nationwide that may not be aware of specific details or
changes within the several MDTs they answered questions for. Thus, despite the high level of
elder abuse involvement seen in the respondent pool, self-report responses may not adequately
reflect the characteristics of MDTs in the U.S. today.
36
Conclusion
This study provided national descriptive data of EA MDTs in the U.S. and showed the
positive perceptions of EA MDTs by EA affiliates. Dissemination of the characteristics and
support for these teams should be targeted to national and state policy makers capable of
supporting the development and improvement of these widespread teams, most of which face
funding and resource barriers. Future research should seek to identify the promising EAFC
model among the pool of 300 EA MDTs identified in this study, distinguish key components,
evaluate outcomes, and explore strategies for effective implementation. This work, which is the
subject of the next chapter, will inform the field by providing a backdrop for more nuanced
research on MDT function, implementation, and effectiveness.

37
CHAPTER 3: USING LATENT CLASS ANALYSIS TO IDENTIFY TYPES OF ELDER
ABUSE MULTIDISCIPLINARY TEAMS
Introduction
Elder abuse (EA) impacts 1 in 10 older adults in the United States and 1 in 6 older adults
globally, and is a growing public health concern (Acierno et al., 2010; Yon et al., 2017). EA has
been shown to be detrimental to older adults’ physical health, mental health, and financial
security. Most of the elder abuse field has reached consensus on five types of abuse:
“(a) physical abuse, which includes acts carried out with the intention to cause physical pain or
injury; (b) psychological abuse, defined as acts carried out with the intention of causing
emotional pain or injury; (c) sexual assault; (d) [financial] exploitation, involving the
misappropriation of the elder’s money or property; and (e) neglect, or the failure of a designated
caregiver to meet the needs of a dependent older person” (Council, 2013; Lachs et al., 1997;
Pillemer, 2016). Self-neglect is an additional related phenomenon that involves an older adult’s
refusal or failure to meet basic requirements related to nutrition, medication, and safety (Dong et
al., 2017). Although self-neglect is fundamentally different from the five types of elder abuse—
since the older adult is both the perpetrator and the victim—it is still a commonly-reported form
of elder mistreatment that is included in elder abuse research and discussion (Mosqueda & Dong,
2011).
EA cases are often complex. Multiple types of EA can occur simultaneously, and the
abuse may involve emotional or instrumental dependence between the perpetrator and victim
(Fingfeld-Connet, 2014). Relatedly, the wishes of an elder abuse victim may be detrimental to
their own health and wellness, creating challenges for professionals seeking an appropriate,
person-centered intervention. For many EA cases, effective remedies require the input of
38
medical, legal, and social professional agencies that are traditionally siloed with little
collaboration (Connolly, 2010). For example, Adult Protective Services (APS) fills reports,
investigates, and provides social services to EA cases, while law enforcement investigates and
recommends criminal prosecution. Elder abuse presents a unique challenge with its various
social, legal, and medical facets, supplemented by the difficulty in defining a “successful”
outcome for cases. EA Multidisciplinary Teams (MDTs) are a widely utilized intervention model
that connects services and supports between professional groups (Connolly, 2010; Wiglesworth
et al., 2006; Wilber, Navarro, & Gassoumis, 2014).
EA MDTs are comprised of professionals from a variety of disciplines coming together
on a regular basis to combat elder abuse. Case review EA MDTs (which are the focus of this
study, henceforth referred to as “MDTs”) review and address individual elder abuse cases to
provide action steps specific to that case. A wide variety of MDTs exist, with different
specializations, catchment areas, and functions/processes. Academic literature and professionals
in practice identify MDTs as a promising intervention for the prevention and resolution of elder
abuse cases (Connolly, 2010; Schneider, Mosqueda, Falk, & Huba, 2010). This well-recognized
intervention, however, is largely understudied and lacks evidence-based research.
The Elder Justice Act of 2010 included provisions supporting the creation and
improvement of a unique MDT model: the Elder Abuse Forensic Center (EAFC) Model. This
model was developed at the University of California, Irvine, and has since been replicated at
other sites in California. Four EAFC sites in California were the focus of qualitative research
seeking to identify core components, including dedicated program staff, medical/legal/social
services professionals in attendance, types of case recommendations, and assistance to frontline
workers (e.g., APS, law enforcement) (Gassoumis, Navarro, & Wilber, 2015; Yonashiro-Cho et
39
al., 2019). However, the model has yet to be tested by quantitative research using a broader cross
section of EAFCs outside of California. The key research questions in this study are: 1) To what
extent can teams be classified according to the EAFC model? 2) Approximately how many
EAFCs exist in the U.S.? and 3) What are the characteristics that distinguish these teams from
other MDTs?

40
Conceptual Framework

41
We use the current EAFC Conceptual Model as a conceptual framework, shown in figure
3.1. This Conceptual Model is based on qualitative research of four EAFCs in California
(Yonashiro et al., 2019). As this model illustrates, an EAFC convenes professionals from three
different perspectives: 1) investigators/direct service providers, 2) client services, and 3) justice
systems to improve client outcomes. This process involves case-related activities and resources
provided by individuals “around the table” to help improve case outcomes for the vulnerable
older adults, as well as the professionals involved in the case, team members, and the general
community. Therefore, the purpose of this study is to use the EAFC conceptual model developed
in the California studies to examine and classify EA MDTs in the U.S., to better understand the
core structures and processes to facilitate replication.
Method
We used key components of the EAFC Conceptual Model as the basis for the survey
instrument used for MDT classification. These key components can be categorized into core
domains that exist in this model: organizational goals, cases, MDT responsibilities, agency
participation, and MDT functions and services. With these domains as a foundation, the present
study uses Latent Class Analysis (LCA) to categorize MDTs. LCA methodology uses observed
data to group subjects based on shared characteristics and was selected because we believe that a
better understanding of the EAFC model’s existence nationwide will allow legislation supporting
EAFCs to be more effective.
Data Source
Data were collected through a survey of MDT key informants nationwide. These key
informants—typically coordinators or leaders of the MDT—were identified in a previous survey
of elder abuse professionals in the U.S. Respondents were sent a personal survey link through
42
Qualtrics that could not be forwarded or shared with other individuals. 117 responses (53.2%)
were collected out of 220 delivered surveys. Respondents were permitted to skip questions,
except for a screening question that confirmed whether a respondent’s MDT qualified as an elder
abuse case review MDT. This screening question had four conditions to allow the respondent to
continue the survey: (1) the team is comprised of professionals from a variety of disciplines, (2)
the team works together on an ongoing basis, (3) the team convenes meetings, either in-person or
by telephone/online, (4) the team meets to review elder abuse cases. Additionally, respondents
who failed to answer more than five of the twelve items used in the Latent Class Analysis (LCA)
were determined to be missing at random and dropped. MDTs were also confirmed to be in
operation at the time the survey was completed. Ultimately, 81 responses were used for the LCA
model.
Expert Panel Review
An elder abuse expert panel provided input for survey development and refinement. The
expert panel consisted of medical professionals, legal professionals, social services professionals,
law enforcement, experienced EA MDT coordinators, and academics. Three iterations of the
survey were sent to the expert panel, in addition to brainstorming/editing sessions via conference
call.
Latent Class Analysis
Latent Class Analysis (LCA) is a technique used to identify a set of implicit subgroups in
a sample, based on selected defining characteristics (Collins & Lanza, 2013). LCA was
conducted on 81 MDTs using the PROC LCA procedure in SAS 9.4. (Lanza, Lemmon Schaefer,
& Collins 2006). Originally, 23 items were selected for inclusion in the analysis, based on the
Elder Abuse Forensic Center Model (Yonashiro-Cho et al., 2019). Several iterations of the LCA
43
model were conducted, with various combinations and operationalizations of variables. To
develop the most parsimonious model, variables that were omitted included: existence of a
mission statement, type of information recorded about cases, number of new cases reviewed per
meeting, tracking of team recommendations, direct services provided to clients by MDT staff or
paid consultants, and services provided to clients by participating agencies. The following twelve
items were ultimately selected for the final model, to maximize model fit and interpretability of
subtypes:
Organizational Goals.
Indicators of Success. This variable was operationalized as binary, between teams that
considered both non-legal and legal indicators of success, versus teams that considered only non-
legal, or only legal indicators of success. The legal indicators of success were
“Guardianship/conservatorship”, “Legal remedies/services provided to client”, “Restitution”, and
“Prosecution or plea”. The non-legal indicators of success were “Improvement in client health
status”, “Improvement in client mental health status”, “Improvement in client quality of life”,
“Preventing recurrence of abuse/victimization”, “Decreased level of risk to client”, “Housing
secured”, “Achieving person-centered outcomes”, and “Other”.
Success Tracking. For each of the indicators of success identified in the previous
variable, respondents were asked to select which indicator is monitored or tracked over time by
their MDT. This variable was dichotomized into MDTs who track indicators and those who do
not.
Cases.
Case Type. Respondents were asked about the types of cases accepted by their MDT.
Answer choices included: self-neglect, hoarding, neglect, abandonment, financial exploitation,
44
physical abuse, sexual abuse, emotional/psychological abuse, and other. This variable was
dichotomized into those who addressed all six types of abuse defined in the most recent APS
Consensus Guidelines and those who did not. The APS Consensus Guidelines identify the
following types of elder abuse: physical abuse, emotional/psychological abuse, sexual abuse,
financial exploitation, neglect, and self-neglect. The APS Guidelines were used due to the large
level of MDT participation from the APS workforce.
Formal Recommendations. Respondents were asked if formal recommendations for EA
cases were given by the MDT, and were given the following answer choices: Never, Rarely,
Sometimes, Often, Always. This variable was coded as “Often” and “Always” versus “Never”,
“Rarely”, and “Sometimes”.
Record Recommendations for Presenter. Respondents were asked if the case
recommendations given by the MDT were intended for the individual who presented the case,
the non-presenting members of the team, or both. In the final model, the variable was coded as
recommendations intended for the case presenter versus not.
Follow Up. Respondents were asked about follow-up and tracking of case
recommendation progress. Answer choices were presented in order of intensity: progress is not
tracked, the individual is asked about progress, the individual is encouraged to complete any
incomplete recommendations, the individual is provided additional resources to complete the
recommendation, or the individual is tasked with a new course of action in place of incomplete
recommendation. This variable was coded as a dichotomous variable, with “individual is asked
about progress” and “progress is not tracked” versus the remaining answer choices.
MDT Responsibilities.
45
Capacity Assessment. Respondents were asked if their MDT has access to someone who
can perform formal capacity assessments that can be used in a courtroom (criminal, civil, or
probate), followed by a list of potential professionals. This list was guided by qualitative EAFC
research and consisted of a geriatrician, psychiatrist, other physician, psychologist, social
worker, or other. This variable was coded into those that did have access versus those who did
not.
Home Visit. Respondents were asked about case-related activities MDT members engage
in as a result of cases being presented to the team. This survey item included several answer
choices: obtaining client/perpetrator records, review of client records, direct services to clients,
home visit, capacity assessment, interviews with third parties, case documentation,
communication between agencies, and other. Based on EAFC literature and model fit, only one
answer choice—home visits—was shown to be viable for inclusion in the final LCA model. This
variable was coded into those who conduct home visits versus those who did not.
Agency Participation.
Forensic Membership (Medical, Legal, Social). Respondents were asked about the
professions represented by the participating agencies in their MDTs, followed by an extensive
list of potential professions, based on EAFC literature. This variable was coded into those who
had all three medical, legal, and social services agency participation, versus those who did not. A
key element of the EAFC model is the integration of these three professional fields in a forensic
case process. Accordingly, this survey item was intended to capture the forensic natures of
teams.
MDT Functions and Services.
46
Facilitates Documents. Respondents were asked about MDT activity outside of normal
meetings, unrelated to case recommendations. Of the activities given to respondents, the answer
choice most pertinent to the latent class analysis was “facilitating the flow of documents and
other information between agencies/organizations”. This answer choice was coded into a binary
variable: those who did facilitate the flow of documents versus those who did not.
MDT Staff. Respondents were asked if their MDT staff consisted of paid program staff,
volunteer program staff, paid consultants, or none. This variable was included based on the
EAFC model—which includes a program coordinator role—in addition to the rationale that
EAFC teams are more likely to have dedicated program staff of some kind. This variable was
coded as binary, into MDT had dedicated program staff versus those that did not.
Meeting Frequency. Respondents were asked about MDT meeting frequency, which was
coded into a binary variable: those that met more frequently than once per month versus those
who met less frequently (quarterly, once per year).
Six LCA models were run, from a two-class model to a seven-class model. Optimal
model selection was based on several indications of model fit: the Akaike Information Criterion
(AIC, Akaike, 1974; Hurvich & Tsai, 1989), the Consistent Akaike Information Criterion (CAIC,
Bozdogan, 1987), the Bayesian Information Criterion (BIC, Schwarz, 1978), Akaike’s Bayesian
Information Criterion (ABIC, Akaike, 1980) frequency distributions of log-likelihoods, entropy,
and the Likelihood Ratio Statistic (G
2
). The model selected was based on low AIC, BIC, and G
2

values, and higher entropy values approaching 1 (Lanza & Rhodes, 2013). Additionally, a
qualitative review of item response probability was conducted to ensure enough difference
between classes. In other words, characteristics of one class should be distinct from another
class.
47

Table 3.1. Descriptive Statistics of Items Used for MDT Latent Classes (N = 81)
Missing Frequency
N (%) N (%)
Organizational Goals
Legal & non-legal indicators of success 2 (.02) 66 (83.54)
Tracks indicators of success 8 (.1) 29 (39.73)
Cases
Addresses 6 types of abuse (APS guidelines) 1 (0.01) 50 (62.50)
Provides formal recommendations on cases 0 50 (61.73)
Records recommendations for the case presenter 9 (.11) 51 (70.83)
Extensive follow-up on case recommendations 8 (.1) 18 (24.66)
MDT Responsibilities
Has access to capacity assessment 6 (.07) 51 (68)
Members conduct home visits due to case presentation 2 (.02) 61 (77.22)
Agency Participation
Medical, legal, & social services in attendance 0 71 (87.65)
MDT Functions and Services
Facilitates the flow of documents between agencies 7 (.09) 45 (60.81)
Has dedicated program staff 0 45 (55.56)
Meets more than once per month 0 40 (49.38)
48
Results
Sample Characteristics
MDT Characteristics. Characteristics of the MDTs used for the latent class analysis are
presented in Table 3.2. Most key informants identified their MDT as an Interdisciplinary Team
(34.6%) or a General MDT (18.5%). Three key informants identified their MDT as a Forensic
Center (3.7%). For the “Other” category, responses included “Adult Protection Team”, “Death
Review Team”, and clarifications of organizational structures. Approximately 40% of teams
were identified as serving a combination of rural and urban areas, followed by primarily rural
(32%) and primarily urban (26%). Two-thirds of teams had no budget for operating costs, and
12% had a budget of less than $500 per month. Four teams (5%) had an operating cost of over
$9000 per month.
In terms of information routinely recorded about cases, case narratives (80.3%),
demographics (72.8%), case timeline (65.4%), finances (55.6%), and psychological assessment
(44.4%) were most frequently selected. A third of teams selected “personal statements from the
client”, followed by “personal statements from witnesses/alleged abusers” (24.7%). For the
“Other” category (17.3%), free responses included “police reports”, WITS, “review of services,
needs, steps in handling cases”, “summary of evidence gathered during the investigation”.
Ninety percent of MDTs addressed financial exploitation, followed by physical abuse
(75.3%), neglect (75.3%), sexual abuse (74.1%), emotional/psychological abuse (71.6%), self-
neglect (67.9%), hoarding (61.7%), and other (16%). The “Other” category free responses
included fatality review, substance use/abuse, confinement/willful deprivation, financial self-
neglect, and murder/suicide.
49
In terms of specific populations served, the majority (92.6%) served older adults ages 65
and above. 76.5% served adults ages 18 to 64, and three (3.7%) served children less than 18
years old. For the “Other” category (7.4%), free responses showed some teams consider the age
threshold for an older adult to be 60 years. Most MDTs served individuals with cognitive
impairment (96.3%), significant physical disability/limited mobility/functional impairment
(95.1%), and intellectual/developmental disabilities (90.1%). Approximately 63% of teams
served individuals with no cognitive impairment, intellectual/developmental disability, or
physical/functional impairment. In the “Other” category (12.35%), free responses included
“chemically-dependent, mental health impairment” and “vulnerable adults”.
50

Table 3.2. MDT Characteristics (N =81)
Item N (%)
Age of MDT
1-5 years 13 (20.63)
6-10 years 16 (25.4)
10+ years 34 (53.97)
Missing = 18
MDT self-classification
I-Team (Interdisciplinary Team) 28 (35)
General MDT 15 (18.75)
CCR (Coordinated Community Response) 9 (11.25)
E-MDT (Enhanced MDT) 8 (10)
FAST (Financial/Fiduciary Abuse Specialist Team) 6 (7.5)
Fatality Review Team/Death Review Team 3 (3.75)
Forensic Center 3 (3.75)
Other (please specify): 8 (10)
Missing = 1
Geography
Combination of rural and urban 33 (41.25)
Primarily rural 26 (32.5)
Primarily urban 21 (26.25)
Missing = 1
Participants receive formal training 30 (37.04)
Operating costs (including salary)
No budget 54 (69.23)
Less than $500/month ($6,000/year) 10 (12.82)
$500-$2,000/month ($6,000-$24,000/year) 5 (6.41)
2,000-$5,000/month ($24,000-$60,000/year) 3 (3.85)
$5,000-$9,000/month ($60,000-$108,000/year) 2 (2.56)
Over $9,000/month ($108,000/year) 4 (5.13)
Missing = 3
Information routinely recorded about cases
Case narrative ("what happened") 65 (80.25)
Demographics (of the client) 59 (72.84)
Case timeline ("what is currently happening to resolve the case") 53 (65.43)
Information about the alleged abuser(s) 52 (64.2)
Finances (of the client) 45 (55.56)
Medical assessment (of the client) 40 (49.38)
Psychological assessment (of the client) 36 (44.44)
Personal statements from client 27 (33.33)
Personal statements from witnesses/alleged abuser(s) 20 (24.69)
Other (please specify): 14 (17.28)
Missing = 11
Type of abuse addressed
Financial 73 (90.1)
Physical 61 (75.31)
Neglect 61 (75.31)
Sexual 60 (74.07)
Emotional 58 (71.6)
Self-Neglect 55 (67.9)
Hoarding 50 (61.73)
Other 13 (16.05)
Missing = 1
Age groups served
Children (<18 years old) 3 (3.7)
Adults age 18 through 64 62 (76.54)
Older adults age 65+ 75 (92.59)
Other 6 (7.41)
Disability groups served
Cognitive impairment 78 (96.3)
Significant physical disability/limited mobility/functional impairment 77 (95.06)
Intellectual/developmental disabilities 73 (90.12)
NO cognitive impairment, intellectual/developmental/physical disability 51 (62.96)
Other 10 (12.35)
Missing = 1
Resources needed
Funds for staffing 29 (35.8)
Physical infrastructure 4 (4.94)
Technology 11 (13.58)
Office supplies 5 (6.17)
Other 11 (13.58)
Missing = 41
51
MDT Meeting Characteristics. Key informants indicated that MDT meetings were held
for 60-90 minutes (80.3%), followed by 90 minutes (11.1%), and under 60 minutes (8.6%). Most
teams (60.5%) reviewed 1-2 cases per meetings, followed by 3-5 cases (27.2%) and 6-10 cases
(11.1%). One team reviewed over 20 cases per meeting (1.23%). Approximately half of teams
(45.7%) reviewed 11-30 cases per year, followed by 1-10 cases (29.6%), 31-50 cases (9.88%),
51-100 cases (9.88%), and over 100 cases per year (3.7%). Most team members participated in
person only (85.2%), followed by in person/telephone (17.3%) and in person/video (2.5%). Most
case presenters participated in person only (85.2%), followed by in person/telephone (7.4%), in
person/video (1.23%; n=1), in person/telephone/video (1.23%, n=1), and telephone only (1.23%,
n=1).
Respondents were asked about indicators of success used by their MDT. 88.9% of teams
used “decreased level of risk to client” as an indicator of success, followed by “improvement in
client quality of life” (85.2%), “preventing recurrence of abuse/victimization” (85.2%),
“improvement in client health status” (72.8%), “legal remedies/services provided to client”
(72.8%), “housing secured” (71.6%), “improvement in client mental health status” (67.9%),
“achieving person-centered outcomes” (66.7%), “guardianship/conservatorship” (61.7%),
“prosecution or plea” (56.8%), and “restitution” (48.2%). For the “Other” category, free
responses choices included “criminal prosecution of perpetrators”, “involved in services”,
“getting illegal conservatorships undone” and “funds returned to victim (not just restitution
ordered)”.
Adult Protective Services (100%) and Law Enforcement (96.3%) were the most common
professions in attendance at MDTs, followed by Case Manager (67.9%), Non-Physician (Other)
Medical Personnel (66.7%), Community-based Mental Health Services (65.4%), Prosecuting
52
Attorney (63%), and Victim Advocate (63%). The least common professions were Psychologist
(17.28%), Elder Abuse Shelter Representative (17.28%), Community Care Licensing (13.58%),
Coroner/Medical Examiner (11.1%), and Forensic Accountant (9.9%). In terms of meeting
attendance, 90.1% (n=81) of key informants identified APS as always attending, followed by
Area Agency on Aging Representative (71.1%; n=45), Case Manager (61.8%; n=55), and MSWs
who perform capacity assessments (52.6%; n=19). Descriptive statistics of each MDT profession
and their relative meeting attendance can be found in Table 3.4.
53

Table 3.3. MDT Meeting Characteristics (N =81)
Item N (%)
Length of Meeting Time
Under 60 minutes 7 (8.64)
60-90 minutes 65 (80.25)
Over 90 minutes 9 (11.11)
Cases reviewed per year
1-10 24 (30)
11-30 37 (46.25)
31-50 8 (10)
51-100 8 (10)
Over 100 3 (3.75)
Missing = 1
Cases reviewed per meeting
1-2 49 (60.49)
3-5 22 (27.16)
6-10 9 (11.11)
11-20 0 --
Over 20 1 (1.23)
Method of participation team members
In person 65 (80.25)
In person & telephone 14 (17.28)
In person & video 2 (2.47)
Method of participation presenters
Telephone 1 (1.28)
In person 69 (88.46)
In person & telephone 6 (7.69)
In person & video 1 (1.28)
In person & telephone & video 1 (1.28)
Missing = 3
Indicators of success
Decreased level of risk to client 72 (88.89)
Improvement in client quality of life 69 (85.19)
Preventing recurrence of abuse/victimization 69 (85.19)
Improvement in client health status 59 (72.84)
Legal remedies/services provided to client 59 (72.84)
Housing secured 58 (71.6)
Improvement in client mental health status 55 (67.9)
Achieving person-centered outcomes 54 (66.67)
Guardianship/conservatorship 50 (61.73)
Prosecution or plea 46 (56.79)
Restitution 39 (48.15)
Other 6 (7.41)
Missing = 2
54

Table 3.4. MDT Professions and Meeting Attendance (N =81)
Professions
Adult Protective Services (APS) 81 (100) 73 (90.12) 4 (4.94) - - 1 (1.23) - - 3 (3.7)
Law Enforcement 78 (96.3) 29 (37.18) 22 (28.21) 14 (17.95) 9 (11.54) 1 (1.28) 3 (3.85)
Case Manager 55 (67.9) 34 (61.82) 12 (21.82) 4 (7.27) - - 2 (3.64) 3 (5.45)
Other Medical Personnel (such as Nurse, PA) 54 (66.67) 23 (42.59) 20 (37.04) 5 (9.26) 3 (5.56) 1 (1.85) 2 (3.7)
Community-based Mental Health Services 53 (65.43) 12 (22.64) 25 (47.17) 8 (15.09) 7 (13.21) - - 1 (1.89)
Prosecuting Attorney 51 (62.96) 18 (35.29) 16 (31.37) 5 (9.8) 6 (11.76) 3 (5.88) 3 (5.88)
Victim Advocate 51 (62.96) 20 (39.22) 15 (29.41) 6 (11.76) 5 (9.8) - - 5 (9.8)
Public Guardian/Conservator 46 (56.79) 23 (50) 10 (21.74) 4 (8.7) 7 (15.22) - - 2 (4.35)
Area Agency on Aging Representative 45 (55.56) 32 (71.11) 8 (17.78) - - 2 (4.44) - - 3 (6.67)
LTC Ombudsman 40 (49.38) 21 (52.5) 5 (12.5) 4 (10) 5 (12.5) 1 (2.5) 4 (10)
Financial Industry Representatives/Personnel 39 (48.15) 8 (20.51) 17 (43.59) 6 (15.38) 3 (7.69) 2 (5.13) 3 (7.69)
Developmental Disability Services 35 (43.21) 11 (31.43) 15 (42.86) 7 (20) 1 (2.86) - - 1 (2.86)
Consulting Attorney 30 (37.04) 11 (36.67) 6 (20) 4 (13.33) 3 (10) 1 (3.33) 5 (16.67)
Non-prosecutory Attorney 26 (32.1) 10 (38.46) 6 (23.08) 4 (15.38) 2 (7.69) - - 4 (15.38)
Other (please specify) 25 (30.86) 4 (16) 5 (20) 2 (8) - - - - 14 (56)
Intimate Partner Violence Services 24 (29.63) 12 (50) 5 (20.83) 3 (12.5) 3 (12.5) - - 1 (4.17)
Senior Legal Aid 22 (27.16) 10 (45.45) 9 (40.91) 1 (4.55) 1 (4.55) - - 1 (4.55)
MSWs (who perform capacity assessments) 19 (23.46) 10 (52.63) 3 (15.79) 2 (10.53) - - 2 (10.53) 2 (10.53)
Physician 16 (19.75) 6 (37.5) 5 (31.25) 2 (12.5) 1 (6.25) 2 (12.5) - -
Psychologist 14 (17.28) 5 (35.71) 3 (21.43) 4 (28.57) 1 (7.14) - - 1 (7.14)
Elder Abuse Shelter Representative 14 (17.28) 4 (28.57) 7 (50) 1 (7.14) 1 (7.14) - - 1 (7.14)
Community Care Licensing 11 (13.58) 1 (9.09) 4 (36.36) 2 (18.18) 3 (27.27) 1 (9.09) - -
Coroner/Medical Examiner 9 (11.11) 1 (11.11) 2 (22.22) 2 (22.22) 2 (22.22) - - 2 (22.22)
Forensic Accountant 8 (9.88) 1 (12.5) 1 (12.5) 3 (37.5) 3 (37.5) - - - -
Rarely Never Unknown
Frequency Meeting Attendance
N (%) Always Often Sometimes
55
MDT Typologies
Model selection. A three-class model was determined to be most appropriate for
classifying MDTs based on interpretability and statistical fit. Each model from two classes to
seven classes showed increasingly improved fit statistics on all metrics (fit statistics can be found
in Appendix C). However, the optimal class solution was not selected on statistical fit alone. The
interpretability of the MDT classes was considered using the distribution of conditional
probabilities (ρ). These conditional probabilities show the likelihood that an MDT has a certain
characteristic used in the LCA model. Distinct conditional probabilities between classes, as well
as homogeneity within classes is preferred. The three-class model showed the most interpretable
separation of classes and showed conditional probabilities that were most credible based on
existing knowledge of MDTs and EAFC. Figures illustrating the conditional probabilities
between two, three, and four class models can be found in Appendix D.
The results of the three-class solution can be found in table 3.5. The three classes were
given category names based on exhibited characteristics. Class 1 was labeled “Elder Abuse
Forensic Center (EAFC)”, because MDTs in this class showed characteristics that aligned with
the most current EAFC Model (Yonashiro-Cho et al., 2019). EAFC MDTs were 32% of the
sample (N=81). Class 2 was labeled “Semi-Elder Abuse Forensic Center (Semi-EAFC)” because
MDTs in this class showed some forensic-oriented qualities (legal and non-legal indicators of
success, medical/legal/social professionals in attendance), but did not exhibit key functional
characteristics seen in the most current EAFC Model (meeting frequency, staff, case follow-up,
success tracking, facilitating the flow of documents between agencies). Semi-EAFC MDTs were
30% of the sample (N=81). Class 3 was labeled “Non-Elder Abuse Forensic Center (Non-
EAFC)” because MDTs in this class showed low conditional probabilities for nearly all
56
characteristics in the model and did not reflect the most current EAFC Model. Non-EAFC MDTs
were 38% of the sample (N=81).
Differences between subtypes. Descriptive statistics of MDTs assigned to each class are
presented in tables 3.6 and 3.7. There was a significant difference between subgroups in terms of
routinely recorded psychological assessment information (χ
2
=7.74; p=.02). More EAFCs (61.5%)
recorded psychological assessment information than Semi-EAFCs (50%) or Non-EAFCs
(25.8%). Statistically significant differences were found between subgroups in terms of type of
abuse addressed, with the exception of financial abuse and the Other category. More Semi-
EAFCs indicated they addressed physical, emotional, sexual, neglect, hoarding, and self-neglect
than EAFCs or Non-EAFCs. Only EAFCs (11.5%) indicated they also serve children under the
age of 18 (χ
2
=6.59; p=.037).
There was a significant difference in cases reviewed each year between classes
(χ
2
=25.27; p=.001). EAFCs reviewed significantly more cases per year than the other subgroups,
with 11.5% of EAFCs seeing over 100 cases per year. Significantly more EAFCs (80%) tracked
success than the other subgroups (χ
2
=25.05; p=<.001). In terms of specific indicators of success,
EAFCs and Semi-EAFCs appear very similar and show significantly more indicators of success
than Non-EAFCs.

57

Table 3.5. Item Response Probabilities for a 3-Class Model of EA MDTs (N =81)
MDT Classes
Characteristic ρ SE ρ SE ρ SE
Organizational Goals
Legal & non-legal indicators of success 0.89 -0.07 1.00 -0.01 0.65 -0.10
Tracks indicators of success 0.78 -0.11 0.31 -0.11 0.13 -0.08
Cases
Addresses 6 types of abuse (APS guidelines) 0.47 -0.11 0.91 -0.10 0.52 -0.10
Provides formal recommendations on cases 0.99 -0.02 0.88 -0.11 0.09 -0.12
Records recommendations for the case presenter 0.93 -0.06 0.82 -0.09 0.36 -0.12
Extensive follow-up on case recommendations 0.51 -0.11 0.16 -0.09 0.06 -0.06
MDT Responsibilities
Has access to capacity assessment 0.75 -0.09 0.74 -0.10 0.56 -0.10
Members conduct home visits due to case presentation 0.88 -0.07 0.85 -0.12 0.62 -0.10
Agency Participation
Medical, legal, & social services in attendance 0.81 -0.08 1.00 -0.02 0.83 -0.07
MDT Functions and Services
Facilitates the flow of documents between agencies 0.78 -0.11 0.47 -0.12 0.57 -0.11
Has dedicated program staff 0.78 -0.09 0.39 -0.13 0.51 -0.10
Meets more than once per month 0.94 -0.06 0.16 -0.12 0.40 -0.10
EAFC Semi-EAFC Non-EAFC
32% 30% 38%
58

Table 3.6. Characteristics Conditional on MDT Class Membership (N =81)
MDT Classes (%)
Characteristic EAFC (n =26) Semi-EAFC (n =24) Non-EAFC (n =31) χ
2
p-value
Age of MDT 5.46 0.243
1-5 years 35.00 9.09 19.05
6-10 years 15.00 36.36 23.81
10+ years 50.00 54.55 57.14
Missing = 18
MDT self-classification 17.61 0.225
I-Team (Interdisciplinary Team) 19.23 45.83 40.00
General MDT 19.23 20.83 16.67
CCR (Coordinated Community Response) 3.85 20.83 10.00
E-MDT (Enhanced MDT) 19.23 4.17 6.67
FAST (Financial/Fiduciary Abuse Specialist Team) 11.54 -- 10.00
Fatality Review Team/Death Review Team 3.85 -- 6.67
Forensic Center 7.69 4.17 --
Other (please specify): 15.38 4.17 10.00
Missing = 1
Geography 3.62 0.460
Combination of rural and urban 30.77 50.00 43.33
Primarily rural 30.77 33.33 33.33
Primarily urban 38.46 16.67 23.33
Missing = 1
Participants receive formal training 42.31 37.50 32.26 0.62 0.735
Operating costs (including salary) 14.92 0.135
No budget 50.00 70.83 83.33
Less than $500/month ($6,000/year) 12.50 16.67 10.00
$500-$2,000/month ($6,000-$24,000/year) 12.50 4.17 3.33
2,000-$5,000/month ($24,000-$60,000/year) 4.17 4.17 3.33
$5,000-$9,000/month ($60,000-$108,000/year) 4.17 4.17 --
Over $9,000/month ($108,000/year) 16.67 -- --
Missing = 3
Information routinely recorded about cases
Case narrative ("what happened") 88.46 75.00 77.42 1.68 0.432
Demographics (of the client) 88.46 70.83 61.29 5.35 0.069
Case timeline ("what is currently happening to resolve the case") 76.92 62.50 58.06 2.35 0.308
Information about the alleged abuser(s) 73.08 62.50 58.06 1.43 0.489
Finances (of the client) 69.23 58.33 41.94 4.37 0.112
Medical assessment (of the client) 65.38 50.00 35.48 5.06 0.080
Psychological assessment (of the client) 61.54 50.00 25.81 7.74 0.021 *
Personal statements from client 46.15 37.50 19.35 4.84 0.089
Personal statements from witnesses/alleged abuser(s) 30.77 29.17 16.13 2.00 0.368
Other (please specify): 23.08 16.67 12.90 1.03 0.597
Missing = 11
Type of abuse addressed
Financial 88.46 100.00 83.87 4.07 0.131
Physical 65.38 100.00 64.52 11.19 0.004 **
Neglect 65.38 100.00 64.52 11.19 0.004 **
Sexual 65.38 100.00 61.29 12.06 0.002 **
Emotional 61.54 95.83 61.29 9.85 0.007 **
Self-Neglect 53.85 100.00 54.84 16.13 0.000 ***
Hoarding 50.00 87.50 51.61 9.60 0.008 **
Other 7.69 16.67 22.58 2.34 0.311
Missing = 1
Age groups served
Children (<18 years old) 11.54 -- -- 6.59 0.037 *
Adults age 18 through 64 69.23 87.50 74.19 2.47 0.290
Older adults age 65+ 96.15 91.67 90.32 0.74 0.690
Other 7.69 4.17 9.68 0.60 0.740
Disability groups served
Cognitive impairment 100.00 91.67 96.77 2.46 0.292
Significant physical disability/limited mobility/functional impairment 100.00 95.83 90.32 2.86 0.239
Intellectual/developmental disabilities 88.46 95.83 87.10 1.28 0.528
NO cognitive impairment, intellectual/developmental/physical disability 69.23 54.17 64.52 1.27 0.531
Other 11.54 4.17 19.35 2.91 0.234
Missing = 1
Resources needed
Funds for staffing 46.15 20.83 38.71 3.67 0.160
Physical infrastructure 7.69 4.17 3.23 0.64 0.725
Technology 11.54 16.67 12.90 0.30 0.861
Office supplies 7.69 4.17 6.45 0.27 0.872
Other 7.69 16.67 16.13 1.13 0.567
Missing = 41
*p < .05. **p < .01. ***p < .001.
59

Discussion
The purpose of this study was to use Latent Class Analysis to classify EA MDTs in the
U.S, using the promising EAFC model as a benchmark. Prior to this study, research on the EAFC
model was primarily based on a systematic study of one site and qualitative studies of four
EAFCs in California (Yonashiro-Cho et al., 2019). Although previous studies provided clarity on
potential defining characteristics of an EAFC, providing empirical evidence for these defining
characteristics by studying other EA MDTs in the U.S. was needed to support funding and
further improvement efforts for these teams. Our results showing 26 EAFCs and 24 Semi-EAFCs
Table 3.7. Characteristics Conditional on MDT Class Membership, Cont. (N =81)
MDT Classes (%)
Characteristic EAFC (n =26) Semi-EAFC (n =24) Non-EAFC (n =31) χ
2
p-value
Length of Meeting Time 0.18 0.996
Under 60 minutes 7.69 8.33 9.68
60-90 minutes 80.77 79.17 80.65
Over 90 minutes 11.54 12.5 9.68
Cases reviewed per year 25.27 0.001 ***
1-10 7.69 33.33 46.67
11-30 42.31 54.17 43.33
31-50 11.54 8.33 10
51-100 26.92 4.17 --
Over 100 11.54 -- --
Missing = 1
Cases reviewed per meeting 10.72 0.097
1-2 53.85 54.17 70.97
3-5 19.23 41.67 22.58
6-10 23.08 4.17 6.45
11-20 -- -- --
Over 20 3.85 -- --
Method of participation team members 8.72 0.069
In person 65.38 87.5 87.1
In person & telephone 34.62 8.33 9.68
In person & video -- 4.17 3.23
Method of participation presenters 13.70 0.090
Telephone -- -- 3.45
In person 76 95.83 93.1
In person & telephone 20 4.17 --
In person & video -- -- 3.45
In person & telephone & video 4 -- --
Missing = 3
Tracks success 79.17 30.43 11.54 25.05 <.001 ***
Indicators of success
Decreased level of risk to client 96.15 95.83 77.42 6.69 0.035 *
Improvement in client quality of life 92.31 95.83 70.97 8.17 0.017 *
Preventing recurrence of abuse/victimization 88.46 91.67 77.42 2.50 0.286
Improvement in client health status 84.62 83.33 54.84 8.24 0.016 *
Legal remedies/services provided to client 80.77 91.67 51.61 12.19 0.002 **
Housing secured 80.77 87.5 51.61 10.15 0.006 **
Improvement in client mental health status 76.92 79.17 51.61 6.14 0.046 *
Achieving person-centered outcomes 76.92 70.83 54.84 3.37 0.186
Guardianship/conservatorship 69.23 75 45.16 6.01 0.050 *
Prosecution or plea 65.38 58.33 48.39 1.70 0.428
Restitution 65.38 58.33 25.81 10.29 0.006 **
Other 11.54 4.17 6.45 1.06 0.590
Missing = 2
*p < .05. **p < .01. ***p < .001.
60
demonstrate that this model exists in other parts of the country and should be investigated
further.
Variations Across Subtype
Consistent with knowledge of the variability of EA MDTs, there are notable differences
across MDTs in each class. The findings support the idea of EA MDTs falling on a spectrum
according to their alignment with the organizational goals, cases, MDT responsibilities, agency
participation, and MDT functions/services of the EAFC model.
EAFCs are particularly distinguishable through their success tracking, formal
recommendations, documentation of recommendations, case follow-up, formal staffing, and high
meeting frequency. EAFCs aligned closely with nearly every LCA item except for abuse type,
which was among the lowest conditional probability scores. A possible reason for this could be
that EAFCs become more specialized over time in order to conserve resources. By contrast,
Semi-EAFCs (which had a high conditional probability score on this item) do not have the same
level of meeting frequency and follow-up and may be able to take on a wider array of cases.
Nearly half (42%) of EAFCs’ participants receive formal training. EAFCs also review
significantly more cases than the other two classes and are the only EA MDTs to have presenters
participate through in-person, telephone, and, video formats. Half of the EAFCs identified from
our sample operate with no funding, which is a surprising finding given the level of staffing seen.
Nevertheless, EAFCs show greater funding support than the other two categories. This suggests
that increased funding support would provide relief to those EAFCs functioning with unpaid staff
and allow other teams access to staffing that could improve services.
Semi-EAFCs, although more similar to EAFCs than Non-EAFCs, generally do not track
success, follow-up on cases already reviewed, have program staff, hold frequent meetings, or
61
facilitate documents between agencies. Semi-EAFCs still retain “EAFC” in their title because of
their alignment with EAFCs on items reflecting philosophical approach: legal and non-legal
indicators of success, and medical/legal/social professionals working together. Semi-EAFCs are
also like EAFCs in their provision of capacity assessments and home visits to clients. However,
the programmatic differences highlighted above are key in distinguishing these two types of EA
MDT. Semi-EAFCs identified from our sample showed a high number of abuse types addressed,
and the majority (70%) operate with no funding.
Non-EAFCs may have medical, legal, and social professionals involved in case review,
but are lacking in every other item used to identify an EAFC. These teams had the lowest case
load, and the vast majority (83%) operate with no funding.
Policy Supporting EAFCs
These findings bring definition and focus to the provisions of the Elder Justice Act of
2010. The EJA details the authorization of funds for the development of Forensic Centers in the
U.S. Our findings demonstrate several ways these funds can be used effectively. First, most of
the EAFCs identified in this study are operating with very little or no budget, including any
budget used for staffing. Funds would support the staffing of these established EAFCs, many
which are functioning on volunteer support and agency dedication alone. Enhancing the power
and scope of these teams with budget support should be a priority on par with the creation of
completely new teams. Relatedly, Semi-EAFCs’ differences from EAFCs were largely related to
tracking, follow-up, and meeting frequency. This suggests that more fiscal and staffing support
for existing Semi-EAFCs—which already uphold the general principles of the EAFC model—
would be a cost-effective way to create more EAFCs. Finally, most EAFCs and Semi-EAFCs do
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not identify themselves as Forensic Centers in their titles. Policy supporting these teams should
look to characteristics of the team and not title alone.
These findings also provide valuable information for policy supporting the creation of
new teams. First, results show that there are a substantial number of EAFCs and Semi-EAFCs
that have been in operation for over a decade. These seasoned teams offer troves of useful
information that could help mitigate some of the difficulties of establishing a completely new
team. Policymakers and MDT advocates should explore avenues for communication between EA
MDT efforts nationwide. This could be used as a platform to troubleshoot or navigate various
barriers that might arise. Additionally, there continues to be a dearth of knowledge regarding the
effectiveness of EAFCs on EA case outcomes. These teams have the potential capacity to
improve EA by providing support and service enhancement, but an evidence base is needed.
Policy should support efforts to evaluate and understand EA outcomes of cases evaluated by
EAFCs.
Furthermore, the indicators of success widely adopted by EAFCs and Semi-EAFCs
provide a foundation for teams or policy looking to create success indicators for cases. Notably,
the most popular indicators of success for EAFCs were not legally oriented, but rather person-
centered, using “decreased level of risk” and “increased quality of life”. Lastly, findings about
EAFC case load, meeting duration, and meeting format may help set reasonable expectations
about the outputs and processes to eventually expect from an EAFC. However, it should be
restated that many of these teams have been in operation for several years, and the figures seen in
this study may not necessarily reflect the characteristics of a completely new team, or teams in
varying geographic locations.
Limitations
63
Sample size was a limitation for this study. Several efforts were made to ensure as many
surveys were completed as possible, including follow-up emails and phone calls to MDT
coordinators. We attempted to identify all MDTs in the United States using a snowballing
sampling technique. We identified 324 unique programs, which we believe is an accurate
reflection of existing MDTs. To collect data for the present study we sent a second survey to
each identified site and received responses from more than half (56%). Because this is the first
study of MDTs in almost two decades, we lack data on the characteristics of those that did not
respond. For example, we do not know if they are still operational and which category they
represent. Due to this small sample size, and the widespread use of EA MDTs across the country,
it is likely that there are several more EAFC or Semi-EAFC teams in the U.S than is shown in our
results. Although this response rate is satisfactory for survey research of this type (Fincham,
2008) a larger percentage of site represented and resulting larger sample size would provide
more for a more statistically powerful and accurate LCA. Nevertheless, this study provided
valuable insights on the EAFC model.
A site visit to one of the EA MDTs—the Denver Forensic Collaborative—suggested this
team would belong in the EAFC category. This observation was based on the similarities
between meetings held at this site and meetings held at the EAFC in Los Angeles, CA. However,
our analysis placed the Denver Forensic Collaborative and the Denver Forensic Collaborative for
At-Risk Adults in the Non-EAFC and Semi-EAFC categories. This discrepancy suggests two
limitations. First, it is uncertain that the “key informants” selected to take the survey were the
optimal contact who could provide reliable information. Some recipients of the survey may have
answered questions to the best of their knowledge, but not given a complete reflection of the
team. It is possible that some teams classified as Semi-EAFCs or even Non-EAFCs would belong
64
in different categories had we received all possible information from the best informant. Second,
this discrepancy highlights a limitation of using Latent Class Analysis to answer this research
question. In this study, we created variables using the EAFC model as a theoretical framework
and used them to identify latent classes among MDTs. Other approaches, with their own
limitations, include using qualitive methods to categorize the MDTs followed by a multinomial
logistic regression analysis. For this analysis, the same sample would be used to qualitatively
identify teams as EAFCs, semi-EAFCs or not an EAFC. Then, we would explore the effect of
our variables on the 3 categories related to EAFC.

65
Conclusion
This study contributes to filling an important gap in the literature of MDT research, and
helps clarify what an EAFC MDT is. This study presents novel findings through primary data
collection and the application of Latent Class Analysis to differentiate types of MDTs. This
classification supports our hypothesis that teams exist on a continuum of how closely they align
with the EAFC model. The provisions of the Elder Justice Act that indicate support for EAFCs
can now be further supported by a list of teams that meet the benchmark qualities of an EAFC.
Additionally, teams that were not characterized as EAFCs that choose to move toward the EAFC
model have information to assist them to take steps in that direction. Policy makers, advocates,
and professionals seeking to form new teams can draw on these findings to inform decisions
about MDT creation and sustainability.

66
CHAPTER 4: PERSPECTIVES FROM AROUND THE TABLE: A DESCRIPTIVE
STUDY ON ELDER ABUSE MULTIDISCIPLINARY TEAM MEMBERS
Introduction
Elder abuse is a crime that affects approximately 5 million—or 1 in 10—older adults in
the United States and can severely impact all facets of an older adult’s well-being (Acierno et al.,
2010). Elder abuse is categorized as distinct types (physical, psychological, sexual, neglect, and
financial exploitation), but can be broadly defined as “intentional actions that cause harm or
create serious risk of harm, whether or not intended, to a vulnerable elder by a caregiver or other
person who stands in a trust relationship to the elder” (Bonnie & Wallace, 2003; Pillemer, 2016).
This serious public health issue carries extreme consequences to individuals and society,
involving repetitive and substantial health, legal, and social services resource use (Dong et al.,
2015). These fields—often siloed in their attempts to address elder abuse cases—are challenged
to effectively navigate the complicated landscape of elder abuse, including relationships between
victim and offender, administrative/bureaucratic tasks related to the case, and understanding the
nuances of defining a successful outcome for a case (Connolly, 2010).
As awareness of elder abuse grows and the elder abuse research field advances,
intervention research is of major interest (Connolly, 2010). The case review Elder Abuse
Multidisciplinary Team (EA MDT) serves as the primary model for elder abuse intervention, in
which professionals from a variety of disciplines come together to review elder abuse cases.
Hundreds of EA MDTs exist across the U.S. that vary in structure, process, scope, and goals
(Galdamez et al., forthcoming). However, EA MDT interventions are not well understood and
lack evidence-based research to support the improvement of existing teams and establishment of
new teams. This study will focus on a critical component of these teams—the members—to
67
develop a better understanding of these individuals’ roles, motivations, perceptions, and what
happens in multidisciplinary collaboration.
The literature on EA MDTs is extremely limited (Malks, Schmidt, & Austin, 2002;
Teaster et al., 2003; Wasylkewycz, 1993). The most substantive body of research related to
members, their experiences, or perceptions focuses specifically on the Elder Abuse Forensic
Center Model, a high-capacity MDT that utilizes forensic science in an in-depth, evaluative
process to resolve cases (Schneider, Mosqueda, Falk, & Huba, 2010; Yonashiro-Cho et al., 2019;
Galdamez et al., forthcoming). This qualitative work with the MDTs in California provides a
platform on which to conduct research focusing on members from MDTs across the U.S.
The purpose of this descriptive study is to illuminate the team dynamics of EA MDTs in
the U.S. using four aims. The first aim is to acquire MDT member information. Little is known
about members’ educational attainment, experience with MDTs and elder abuse, or motivations
for participating in an MDT. In addition to providing valuable information for current
coordinators of MDTs, this domain will provide a context in which to analyze the findings of this
study, particularly if notable differences arise by type of respondent that could signal new
research topics of interest.
The second aim is to understand the MDT case review process from the perspective of
team members, including priorities in decision making, handling disagreements, and
collaborations with participating agencies. Our understanding of the case review process is
limited to the EAFC model, which includes process information (e.g. “the case review process
entailed an initial presentation, followed by a discussion in which team members asked questions
to the presenters for clarification and to obtain further information”), but does not quantitatively
capture interpersonal dynamics of the team.
68
The third aim is to understand team member perceptions of MDT success, in addition to
impacts the MDT might have on members’ professional practice. Capturing this from a member
perspective will develop a better understanding of how MDTs measure success, which is
considered a key priority in elder abuse intervention research. This domain will also include an
adapted team effectiveness inventory to capture how well MDTs work together, from the
perspective of the members.
The fourth and final aim is to capture member perspectives on the creation of new MDTs.
With the potential provision of funding for elder abuse interventions, it is crucial to prepare
empirical evidence for the implementation of these interventions. Part of this preparation
includes the perspectives of individuals who experienced the process of building a new team.
Methods
Data
Data were collected by distributing a survey to team members of MDTs across the U.S.
These team members were identified using a related survey previously distributed to EA MDT
coordinators in the U.S. (n=117). MDT coordinators were contacted and asked to solicit
permission and contact information from members on the MDT. MDT members whose contact
information was provided were sent an anonymous survey link through Qualtrics. MDT
coordinators were also sent the survey link to forward to members who were not willing to share
their contact information. A total of 136 survey links were sent directly to team members. 89
started the survey, and 75 (55%) completed responses were collected. Four attempts were made
to remind respondents to complete or begin the survey.
Prior to survey implementation, the survey was sent to an expert panel for review. This
panel consisted of professionals from legal, social, medical, EA MDT, law enforcement, and
69
academic fields (clinical psychology). Following the principles of the Delphi process, the survey
underwent three rounds of review through email correspondence, and two additional rounds of
review through conference calls and in-person meetings before reaching consensus on survey
items (Dalkey & Helmer-Hirschberg, 1962). The survey included items on respondent
characteristics, case processes, MDT perceptions and impacts, and MDT creation.
Survey Items
Respondent Characteristics.
Education. Categorized as “less than HS”, “high school diploma”, “Bachelor’s degree”,
and “Graduate degree.
Agency. Respondents were asked about the agency they represent. This item was a free
response question, and was qualitatively coded into medical, legal, and social services categories.
Web searches were used to confirm the accuracy of some free response categorizations, some of
which included organization names and acronyms.
Involved in other MDTs. Respondents were asked if they were involved in any additional
MDTs than the one being asked about in the survey, which was binary as “yes” or “no”.
Respondents who answered “yes” were sent additional surveys corresponding to the MDTs
identified.
Length of MDT Participation. Categorized as “less than 1 year”, “1-2 years”, “3-5
years”, “6+ years”.
Meeting Attendance. Respondents were asked how often they attend meetings. This was
categorized as “weekly”, “less than 1 year”, “1-2 years”, “3-5 years”, and “6+ years”. An “other”
category with a free response text box was also provided.
70
Experience in Elder Abuse. Respondents were asked how long they had worked on cases
of elder mistreatment before participating in the MDT. This was categorized as “never”, “less
than 1 year”, “1-2 years”, “3-5 years”, “6+ years”.
First Aware of MDT. Respondents were asked how they first became aware of their
MDT. This was categorized as “my job/organization”, “email from this MDT”, “internet search”,
“word of mouth”. An “other” category was provided with a free response option.
Reason for Joining. Respondents were asked why they decided to join this MDT as a
team member. The following options were given: “monetary compensation from the MDT”,
“requirement set by my job/organization”, “seemed like a gratifying experience”, “to help
address difficult elder abuse cases in my professional work”, “professional networking
opportunities”, and “other” (with a free response option). Respondents were able to select more
than one option.
Reason for Continued Participation. Respondents were asked about what drives them to
keep participating in this MDT as a team member. The following options were given: “monetary
compensation from the MDT”, “requirement set by my job/organization”, “it is a gratifying
experience”, “it has helped address difficult elder abuse cases in my professional work”,
“professional networking opportunities”, and “other” (with a free response option). Respondents
were able to select multiple answers.
Case Processes
Top Priority (MDT). Respondents were asked to identify the top priority of their MDT in
the case review and decision-making process. The following options were given: “client
safety/protection”, “supporting client self-determination”, “facilitating client wishes”, “cost
71
effectiveness”, “legal action”, “client’s desires/wishes”, “client’s physical and mental health”,
“other” (with a free response option), and “don’t know”.
Top Priority (Agency). Respondents were asked to identify the top priority of their
Agency in the case review and decision-making process. Answer choices for this item were the
same as above.
Top Priority (Personal). Respondents were asked to identify their personal top priority in
case review and decision-making. Answer choices were the same as Top Priority (MDT).
Client Wishes. Respondents were asked if case discussions include the client’s desires or
wishes and was categorized as “yes” or “no”.
Adjust Case Plan for Client Wish. Respondents were asked how often a case plan is
adjusted if a client’s desires/wishes would oppose the plan. This was categorized as “always”,
“often”, “sometimes”, “rarely”, and “never”.
Disagree with Case Decision. Respondents were asked how often they have disagreed
with a decision made on a case, regardless of whether they expressed their disagreement to the
team. This was categorized as “always”, “often”, “sometimes”, “rarely”, and “never”.
Disagreements Made Known. Respondents were asked how often they make their
disagreements known to the MDT. This was only asked of those who responded “always”,
“often” or “sometimes” on the Disagree with Case Decision item his was categorized as
“always”, “often”, “sometimes”, “rarely”, and “never”.
Agencies Offer Help. Respondents were asked how often the participating agencies offer
each other assistance to work around case plan barriers. Respondents were given an example for
this item: APS is unable to contact an elder’s physician, but a physician on the MDT offers help
72
contacting the older adult’s physician. This item was categorized as “always”, “often”,
“sometimes”, “rarely”, and “never”.
Member Reaches Out to Agency. Respondents were asked how often they reach out to
other participating agencies on their MDT for assistance with a case. This item was categorized
as “always”, “often”, “sometimes”, “rarely”, and “never”.
Member Reached Out Before Joining. Respondents were asked how often they reached
out to other participating agencies on their MDT prior to becoming a member of the MDT. This
item was categorized as “always”, “often”, “sometimes”, “rarely”, and “never”.
Unable to Voice Opinion. Respondents were asked if they ever felt unable to properly
voice their opinion or suggestion during an MDT meeting. This was categorized as “yes” or
“no”.
Reason for No Voice. Respondents were asked to select the reasons for not being able to
voice their opinion or suggestion. Answer choices included: “other team members cut me off”,
“other team members dominate the conversation”, “I am not comfortable with public speaking”,
“the meeting ran out of time”, “my opinion/suggestion would not have been received well by the
team”, and “other”. A free response option was given for the “other” choice. Respondents were
able to select multiple answers.
MDT Perceptions and Impacts
Operational with Leader Change. Respondents were asked if their MDT would remain
in operation after a change in leadership. This was categorized as a 5-point Likert scale from
“strongly agree” to “strongly disagree”.
73
Participate with Leader Change. Respondents were asked if they would remain a
participant in their MDT after a change in MDT leadership. This was dichotomized as “yes” or
“no”.
MDT Level of Success. Respondents were asked to rate their MDT’s level of success. A
7-point Likert scale was used, from “very successful” to “very unsuccessful”.
Personal Contribution to MDT Success. Respondents were asked to rate their personal
contribution to the overall success of their MDT. A 5-point Likert scale was used, from “strongly
agree” to “strongly disagree”.
Agency Contribution to MDT Success. Respondents were asked to rate their agency’s
contribution to the overall success of their MDT. A 5-point Likert scale was used, from “strongly
agree” to “strongly disagree”.
Relationships with MDT Agencies Impact. Respondents were asked how their
relationship with participating agencies in the MDT has impacted their work/practice. A 7-point
Likert scale was used, from “very positively” to “very negatively”.
Overall Participation Impact. Respondents were asked how their overall participation in
their MDT has impacted their work or practice. Answer choices were placed on a 7-point Likert
scale from “very positively” to “very negatively”.
Team Effectiveness Inventory. Subjective team effectiveness was measured using a
team effectiveness inventory adapted from Kormanski & Mozenter (1987). Some items in this
inventory overlapped with the other target domains in the survey instrument but provided a more
nuanced understanding of MDT effectiveness. All items in the inventory were categorized on a
5-point Likert scale from “strongly agree” to “strongly disagree”. The inventory measures the
following domains: member influence on team decisions, team member skills to complete tasks,
74
understanding of MDT’s priorities, working together to achieve goals, overcoming barriers and
conflicts, open and honest communication, resources and supports, physical layout of the MDT,
mentoring of new members, and overall effectiveness.
Creation of MDT.
Aware of Resources. Respondents were asked if they are aware of resources that would
guide someone trying to establish an MDT like theirs. A free response text option followed this
item.
Involved in MDT Creation. Respondents were asked if they were involved in the
creation of their MDT, categorized as “yes” or “no”.
Challenging to Create MDT. Of those who responded that they were involved in the
creation of their MDT, respondents were asked how difficult it was to establish their MDT. This
was categorized as “extremely challenging”, “challenging”, “somewhat challenging”, “not
challenging”.
Barriers to Establishment. Respondents were asked about major barriers in establishing
their MDT. Answer choices for this item included: “acquiring sufficient funds”, “recruiting
participating agencies”, “finding cases to review”, “establishing support from policymakers”,
“conflict over mission and purpose”, “navigating confidentiality and other coordination issues”,
“developing an effective team environment”, “other”, and “no major barriers”.
Statistical Analysis
Univariate descriptive statistics were calculated on each survey item using SAS 9.4. To
explore and understand differences between members, bivariate statistics were calculated on
survey items of interest by respondent education, length of experience in elder abuse, and
professional group. Chi-squared was used to determine statistical significance.
75
Results
Respondent Characteristics
Two respondents had high school diplomas. Most had at least a college education, and
over half had graduate degrees (54%, n=74). Most respondents (81%, n=75) represented a social
services agency, followed by legal (16%) and medical (2.7%). Approximately one third
participated in their MDT for less than 1 year, 1-2 year, and 3-5 years, respectively (n=74). Only
5% participated in their MDT for over 6 years. Members’ experience in elder abuse before
participating in the MDT varied: one third (32.4%, n=74) had 6+ years’ experience, followed by
no experience (24.3%), 3-5 years (17.6%), 1-2 years (14.9%), and less than one year (10.8%).
One fourth (26.7%, n=75) were involved in additional MDTs. Most respondents first became
aware of their MDT through their job/organization (83.6%, n=73). For the “other” free response
category, respondents indicated that they either started the MDT, were personally invited, or
worked with an organization that started the MDT. Most respondents attended MDT meetings
once per month (41.9%, n=74), followed by other (28.4%), 2-3 times per month (14.9%), and
weekly (4.1%). For the “other” free response category, respondents indicated quarterly meeting
attendance, sporadic meeting attendance, and monthly meeting attendance with a summer break
from May to September.
In terms of reason for joining, most respondents selected “help address elder abuse cases
in professional work” (65.6%, n=73) and “requirement set by job/organization” (53.4%). Almost
one third selected “gratifying experience” (28.8%) and more than half chose “networking
opportunities” (56.2%). None selected “monetary compensation”. For the “other” free response
category (12.3%), respondents cited employment opportunity, resources for collaboration, and
meeting needs for vulnerable older adults. In terms of reasons for remaining a member of the
MDT, most respondents selected “requirement set by job/organization” (56%, n=73), “gratifying
76
experience” (57.5%), and “professional networking opportunities” (56.1%). Slightly fewer
respondents selected “improved job performance” (41.4%). In the “other” free response category
(16.4%), respondents cited moral responsibility (“actually doing good”, “it is the right thing to
do”), as well as resources for difficult cases (“great input on difficult cases”, “respect and
admiration for the work of team members, in particular APS”).
77

Table 4.1. MDT Member Characteristics
Item Frequency Percent
Education
High school 2 2.7
Bachelor's degree 32 43.24
Graduate degree 40 54.05
Missing: 1
Agency
Medical 2 2.67
Legal 12 16
Social 61 81.33
Involved in other MDTs 20 26.67
Length of MDT participation
Less than 1 year 22 29.73
1-2 years 24 32.43
3-5 years 24 32.43
6+years 4 5.41
Missing: 1
Meeting attendance
Weekly 3 4.05
2-3 times per month 11 14.86
Once per month 31 41.89
Every other month 8 10.81
Other 21 28.38
Missing: 1
Experience in elder abuse before MDT participation
Never 18 24.32
Less than 1 year 8 10.81
1-2 years 11 14.86
3-5 years 13 17.57
6+ years 24 32.43
Missing: 1
How member first became aware of MDT
Job/organization 61 83.56
Email from the MDT 2 2.74
Internet search 1 1.37
Word of mouth -- --
Other 9 12.33
Missing: 2
Reason for joining the MDT
Monetary compensation from MDT -- --
Requirement set by job/organization 39 53.42
Seemed like a gratifying experience 21 28.77
Help address elder abuse cases in professional work 48 65.75
Professional networking opportunities 23 31.51
Other 9 12.33
Missing: 2
Reason for continued participation
Monetary compensation from MDT -- --
Requirement set by job/organization 41 56.16
Gratifying experience 42 57.53
Improved job performance 30 41.1
Professional networking opportunities 41 56.16
Other 12 16.44
Missing: 2
78
Case Processes
Responses for priorities for case decision making were similar for the MDT, agency, and
member. The most popular priority was “client safety/protection” (69.9% MDT, 56.2% Agency,
58.9% Personal, n=73), followed by “supporting client self-determination” (9.6% MDT, 17.8%
Agency, 23.3% Personal), and “client physical and mental health” (6.9% MDT, 9.59% Agency,
8.2% Personal). The “other” (5.5%) free response option for MDT Top Priority included a
“balance of all of the above”, “case/situation specific”, and notes that some categories could not
be separated. The “other” free responses for Agency Top Priority (5.5%) and Personal Top
Priority (5.5%) showed similar information.
In terms of the case decision-making process, most respondents indicated that the client’s
wishes were included (94.5%, n=73). Most respondents indicated that if the client’s wishes
contradict the case plan, the case plan is adjusted Often (37.7%, n=69) or Sometimes (53.6%).
Respondents indicated that they rarely (57.1%) or sometimes (25.7%) disagree with case
decisions. Of those that indicated they disagree (n=20), half indicated that they sometimes make
their disagreement known to the team, followed by “often” (25%), “always” (20%), and “rarely”
(5%). Regarding whether a case decision is reevaluated when a member or agency voices
dissent, most respondents agreed (60%, n=70), a few strongly agreed (8.6%), and one third
(30%) were neutral. One respondent disagreed (1.4%). Three respondents from separate teams
indicated that they are unable to properly to voice their opinion or suggestion, and all three
selected “opinion/suggestion would not have been received well by the team” as the reason.
Items on collaboration between members and other participating agencies showed that
agencies offer help addressing case barriers often (47.9%, n=71), followed by “sometimes”
(22.5%), “always” (18.31%), “rarely” (9.9%), and “never” (1.4%). Most respondents indicated
79
that they reach out to other participating agencies for case help often (57.8%, n=71), sometimes
(22.5%), or always (12.7%). Similarly, most respondents indicated they reached out to other
agencies prior to joining the MDT often (38%, n=71), sometimes (31%), or always (8.5%). One
fifth of respondents indicated they rarely (18.3%) or never (4.2%) reached out to other
participating agencies prior to joining the MDT.
80

Table 4.2. MDT Case Review Process: MDT Member Perspectives
Item Frequency Percent
Top priority in case decision making (MDT)
Client safety/protection 51 69.86
Supporting client self-determination 7 9.59
Facilitating client wishes -- --
Cost effectiveness -- --
Legal action 2 2.74
Client desires/wishes -- --
Client's physical and mental health 5 6.85
Other 4 5.48
Don't Know 4 5.48
Missing: 2
Top priority in case decision making (Agency)
Client safety/protection 41 56.16
Supporting client self-determination 13 17.81
Facilitating client wishes 2 2.74
Cost effectiveness 1 1.37
Legal action 2 2.74
Client desires/wishes 2 2.74
Client's physical and mental health 7 9.59
Other 4 5.48
Don't Know 1 1.37
Missing: 2
Top priority in case decision making (Personal)
Client safety/protection 43 58.9
Supporting client self-determination 17 23.29
Facilitating client wishes 1 1.37
Cost effectiveness -- --
Legal action 1 1.37
Client desires/wishes 1 1.37
Client's physical and mental health 6 8.22
Other 4 5.48
Don't Know -- --
Missing: 2
Case discussions include client wishes 69 94.52
Missing: 2
Case plan is adjusted if client wishes contradict
Always 3 4.35
Often 26 37.68
Sometimes 37 53.62
Rarely 2 2.9
Never 1 1.45
Missing: 6
Disagreement with case decisions
Always -- --
Often 3 4.29
Sometimes 18 25.71
Rarely 40 57.14
Never 9 12.86
Missing: 5
Disagreements are made known
Always 4 20
Often 5 25
Sometimes 10 50
Rarely 1 5
Never -- --
Missing: 55
Agencies offer help for case barriers
Always 13 18.31
Often 34 47.89
Sometimes 16 22.54
Rarely 7 9.86
Never 1 1.41
Missing: 4
Member reaches out to agencies for case help
Always 9 12.68
Often 41 57.75
Sometimes 16 22.54
Rarely 5 7.04
Never -- --
Missing: 4
Member reached out to agencies before joining MDT
Always 6 8.45
Often 27 38.03
Sometimes 22 30.99
Rarely 13 18.31
Never 3 4.23
Missing: 4
If member/agency voices dissent, decision is reevaluated
Strongly agree 6 8.57
Agree 42 60
Neutral 21 30
Disagree 1 1.43
Strongly disagree -- --
Missing: 5
Unable to voice opinion/suggestion 3 4.23
Missing: 4
Reason for not voicing opinion/suggestion
Opinion/suggestion would not have been received well 3 100
Missing: 72
81
MDT Success and Impacts
Most respondents indicated that their MDT is successful (62.3%, n=69), very successful
(18.8%), or somewhat successful (14.5%). Fewer respondents remained neutral (2.9%) or
indicated their MDT was somewhat unsuccessful (1.5%). Most respondents agreed (56.9%,
n=65) or strongly agreed (33.9%,) that they personally contribute to their MDT’s success, and
most strongly agreed (49.2%, n=65) or agreed (36.9%) that their agency contributes to their
MDT’s success. Most respondents strongly agreed (45.2%, n=73) or agreed that their MDT
would remain operational after a change in leadership, and that they would continue to
participate in the MDT after a change in leadership (87.3%, n=71). Respondents indicated that
their relationships with MDT agencies has impacted their work or practice very positively
(45.1%, n=71), positively (40.9%), or somewhat positively (12.7%). A similar pattern arose
when asked about their overall participation in the MDT impacting their work or practice, with
most responding very positively (43.7%), positively (43.7%) or somewhat positively (9.9%).
82

Table 4.3. MDT Characteristics and Impacts
Item Frequency Percent
MDT would remain operational with leader change
Strongly agree 33 45.21
Agree 24 32.88
Neutral 10 13.7
Disagree 5 6.85
Strongly disagree 1 1.37
Missing: 2
Member would continue to participate with leader change 62 87.32
Missing: 4
MDT level of success
Very successful 13 18.84
Successful 43 62.32
Somewhat successful 10 14.49
Neutral 2 2.9
Somewhat unsuccessful 1 1.45
Unsuccessful -- --
Very unsuccessful -- --
Missing: 6
Personal contribution to MDT success
Strongly agree 22 33.85
Agree 37 56.92
Neutral 6 9.23
Disagree -- --
Strongly disagree -- --
Missing: 10
Agency contribution to MDT success
Strongly agree 32 49.23
Agree 24 36.92
Neutral 9 13.85
Disagree -- --
Strongly disagree -- --
Missing: 10
Relationships with MDT agencies impacted work/practice
Very positively 32 45.07
Positively 29 40.85
Somewhat positively 9 12.68
No effect 1 1.41
Somewhat negatively -- --
Negatively -- --
Missing: 4 -- --
Overall MDT participation impacted work/practice
Very positively 31 43.66
Positively 31 43.66
Somewhat positively 7 9.86
No effect 2 2.82
Somewhat negatively -- --
Negatively -- --
Very Negatively -- --
Missing: 4
83
Team Effectiveness Inventory
Respondents were asked to complete an adapted team effectiveness inventory. Most
(n=70) strongly agreed or agreed with most items in the inventory. The items with the most
neutral or negative responses were “team has support and resources to meet goals” (25.7%
neutral, 18.6% disagree, 4.3% strongly disagree), “team is supportive and provides essential
mentoring for new people (22.9% neutral, 2.9% disagree, 1.4% strongly disagree), and
“everyone has equal influence on decisions” (14.3% neutral, 4.3% disagree, 2.9% strongly
disagree).
84

Table 4.4. Results of Adapted Team Effectiveness Inventory
Item Frequency Percent
Everyone on my team has equal influence on the team's decisions
Strongly agree 11 15.71
Agree 44 62.86
Neutral 10 14.29
Disagree 3 4.29
Strongly disagree 2 2.86
Team members have the skills to contribute to the task we have been assigned
Strongly agree 23 32.86
Agree 42 60
Neutral 4 5.71
Disagree -- --
Strongly disagree 1 1.43
Everyone on this team knows and understands the team's priorities
Strongly agree 15 21.43
Agree 41 58.57
Neutral 11 15.71
Disagree -- --
Strongly disagree 1 1.43
As a team, we work together to set clear, achievable, and appropriate goals
Strongly agree 20 28.57
Agree 34 48.57
Neutral 13 18.57
Disagree 2 2.86
Strongly disagree 1 1.43
As a team, we are able to work together to overcome barriers and conflicts
Strongly agree 23 32.86
Agree 35 50
Neutral 11 15.71
Disagree -- --
Strongly disagree 1 1.43
The team environment encourages every person on the team to be open and honest
Strongly agree 28 40
Agree 35 50
Neutral 6 8.57
Disagree -- --
Strongly disagree -- --
The team has the support and resources it needs to meet its goals
Strongly agree 7 10
Agree 29 41.43
Neutral 18 25.71
Disagree 13 18.57
Strongly disagree 3 4.29
The physical layout of the MDT promotes team interaction
Strongly agree 25 35.71
Agree 35 50
Neutral 8 11.43
Disagree 1 1.43
Strongly disagree 1 1.43
The team is supportive and provides essential mentoring for new people
Strongly agree 19 27.14
Agree 32 45.71
Neutral 16 22.86
Disagree 2 2.86
Strongly disagree 1 1.43
Overall, this MDT is effective
Strongly agree 30 42.86
Agree 33 47.14
Neutral 5 7.14
Disagree 1 1.43
Strongly disagree 1 1.43
Missing: 5
85
MDT Creation
A third of respondents (33.9%, n=62) were aware of resources that might be helpful to
those aiming to establish a new MDT. Slightly over one third (36%, n=64) were involved in the
creation of the MDT they participated in. In terms of difficulty of MDT establishment,
approximately half (47.8%, n=23) indicated it was somewhat challenging to create their MDT,
followed by challenging (37.8%), extremely challenging (13%), and not challenging (4.4%). The
most common major barrier to MDT establishment were recruiting participating agencies (50%,
n=64) acquiring sufficient funds (28.1%), finding cases to review (28.1%). In the “other”
category free response (10.9%), respondents noted “obtaining and establishing infrastructure”
and lack of knowledge of what an MDT was prior to starting one.

Table 4.5. Member Perspectives on MDT Establishment
Item Frequency Percent
Aware of resources to start new MDTs 21 33.87
Missing: 13
Involved in creation of MDT 23 35.94
Missing: 11
Challenging to create MDT
Extremely challenging 3 13.04
Challenging 8 34.78
Somewhat challenging 11 47.83
Not challenging 1 4.35
Major barriers in establishing MDT
Acquiring sufficient funds 18 28.13
Recruiting participating agencies 32 50
Finding cases to review 18 28.13
Establishing support from policymakers 11 17.19
Conflict over mission and purpose -- --
Navigating confidentiality and other coordination issues 11 17.19
Developing an effective team environment 12 18.75
Other 7 10.94
There were no barriers in establishing MDT 5 7.81
Missing: 11
86
Bivariate Analysis
Differences by Education.
Some notable differences were found on survey items across respondent educational
groups. Respondents with a bachelor’s degree (n=31) showed higher proportions across all
reasons for joining the MDT than those with graduate degrees (n=39). 45.2% of bachelor’s
degree holders selected “seemed like a gratifying experience” versus 15.4% of graduate degree
holders (n=69, χ
2
=7.84, p =.02). Similarly, 51.6% of bachelor’s degree holders selected
“professional networking opportunities”, versus 15.4% of graduate degree holders (χ
2
=10.74,
p=.005). Similar but smaller differences were found between education groups in terms of
reasons for continued MDT participation. 74.2% of bachelor’s degree holders selected
“requirement set by job/organization” versus 46.2% of graduate degree holders (n=69, χ
2
=8.26,
p=.02). 51.6% of bachelor’s degree holders selected “improved job performance” versus 33.3%
of graduate degree holders (χ
2
=3.79, p=.15). 10% of bachelor’s degree holders indicated they
disagree with case decisions often, as opposed to no graduate degree holders (n=69, χ
2
=13.11,
p=.04).
More bachelor’s degree holders indicated they “always” reach out to agencies for case
help than graduate degree holders (23.3% versus 5.3%), but less indicated they “often” reach out
(46.7% versus 71.1%) (n=67, χ
2
=13.74, p=.03). 6.7% of bachelor’s degree holders indicated they
never reached out to agencies prior to joining the MDT, as opposed to no graduate degree
holders (n=67, χ
2
=21.29, p=.01). In terms of overall MDT participation impacting work/practice
(n=70), graduate degree holders selected “very positively” more often (50% versus 36.7%,
χ
2
=18.89, p=.004 ), while bachelor’s degree holders selected “positively” more often (50%
87
versus 39.5%). 47.1% of graduate degree holders were involved in the creation of their MDT,
versus 22.2% of bachelor’s degree holders (n=63, χ
2
=5.19, p=.07).

Table 4.6. Differences in Responses by Respondent Education
Education
Characteristic Graduate Degree (n =39) Bachelor's Degree (n =31) High School Diploma (n =2) χ
2
p-value
Reason for joining MDT
Monetary compensation from MDT -- -- -- -- --
Requirement set by job/organization 43.59 70.97 -- 7.65 0.02 *
Seemed like a gratifying experience 15.38 45.16 50 7.84 0.02 *
Help address elder abuse cases in professional work 58.97 74.19 50 1.98 0.37
Professional networking opportunities 15.38 51.61 50 10.74 0.005 **
Other 7.69 16.13 50 3.77 0.15
Missing: 3
Reason for continued participation
Monetary compensation from MDT -- -- -- -- --
Requirement set by job/organization 46.15 74.19 -- 8.26 0.02 *
Gratifying experience 53.85 61.29 50 0.43 0.81
Improved job performance 33.33 51.61 -- 3.79 0.15
Professional networking opportunities 46.15 67.74 50 3.29 0.19
Other 15.38 16.13 -- 0.38 0.83
Missing: 3
Disagrees with Decisions 13.11 0.04 *
Always -- -- --
Often -- 10 --
Sometimes 18.92 33.33 --
Rarely 72.97 40 --
Never 8.11 16.67 50
Missing: 6
Member reaches out to agencies for case help 13.74 0.03 *
Always 5.26 23.33 --
Often 71.05 46.67 --
Sometimes 18.42 23.33 50
Rarely 5.26 6.67 50
Never -- -- --
Missing: 5
Member reached out to agencies before joining MDT 21.29 0.01 *
Always 2.63 16.67 --
Often 52.63 23.33 --
Sometimes 26.32 33.33 --
Rarely 18.42 20 --
Never -- 6.67 50
Missing: 5
Overall MDT participation impacted work/practice 18.89 0.004 **
Very positively 50 36.67 --
Positively 39.47 50 50
Somewhat positively 10.53 10 --
No effect -- 3.33 50
Somewhat negatively -- -- --
Negatively -- -- --
Very Negatively -- -- --
Missing: 5
Personal contribution to MDT success 20.44 <.001 ***
Strongly agree 34.29 33.33 --
Agree 57.14 62.96 --
Neutral 8.57 3.7 100
Disagree -- -- --
Strongly disagree -- -- --
Missing: 11
Involved in the creation of MDT 47.06 22.22 -- 5.19 0.07
Missing: 12
*p < .05. **p < .01. ***p < .001.
88
Differences by Elder Abuse Case Experience.
60.9% of those with 6+ years of experience with elder abuse cases were involved in the
creation of their MDT, more than any other category (n=63, χ
2
=10.01, p=.04). In terms of reason
for continued participation, most of the individuals with 3-5 years’ experience (76.9%) and less
than 1 year experience (75%) selected “requirement set by organization”, versus those with 6+
years (37.5%) and 1-2 years (36.4%) (n=73, χ
2
=10.01, p=.04).
89

Table 4.7. Differences in Responses by Respondent Elder Abuse Case Experience (Prior to MDT Membership)
Experience with Elder Abuse Cases
Characteristic 6+ years (n=24) 3-5 years (n=13) 1-2 years (n=11) Less than 1 year (n=8) Never (n=18) χ
2
p-value
Reason for joining MDT
Monetary compensation from MDT -- -- -- -- -- -- --
Requirement set by job/organization 41.67 69.23 36.36 62.5 64.71 5.06 0.28
Seemed like a gratifying experience 20.83 38.46 18.18 50 29.41 3.70 0.45
Help address elder abuse cases in professional work 79.17 61.54 72.73 50 52.94 4.38 0.36
Professional networking opportunities 37.5 38.46 18.18 25 29.41 1.79 0.77
Other 4.17 38.46 9.09 12.5 5.88 10.45 0.03 *
Missing: 2
Reason for continued participation
Monetary compensation from MDT -- -- -- -- -- -- --
Requirement set by job/organization 37.5 76.92 36.36 75 70.59 10.01 0.04 *
Gratifying experience 58.33 61.54 54.55 75 47.06 1.89 0.76
Improved job performance 37.5 46.15 36.36 62.5 35.29 2.12 0.71
Professional networking opportunities 54.17 76.92 36.36 62.5 52.94 4.27 0.37
Other 33.33 15.38 18.18 -- -- 9.94 0.04 *
Missing: 2
Involved in the creation of MDT 60.87 23.08 22.22 12.5 27.27 10.15 0.04 *
Missing: 12
*p < .05. **p < .01. ***p < .001.
90
Differences by Professional Group
In terms of reason for joining the MDT, a larger proportion of social services respondents
(62.7%) identified “requirement set by job/organization” than the other professional groups
(n=73, χ
2
=10.86, p=.004). A larger proportion of legal services respondents identified “help
address elder abuse cases in professional work” than the other professional groups (χ
2
=5.7,
p=.06). Additionally, more social services respondents identified “requirement set by
job/organization” as a reason for continued participation than the other professional groups
(χ
2
=12.53, p=.002).
91

Table 4.8. Differences in Responses by Respondent Professional Group
Professional Group
Characteristic Social (n=61) Legal (n=12) Medical (n=2) χ
2
p-value
Reason for joining MDT
Monetary compensation from MDT -- -- -- -- --
Requirement set by job/organization 62.71 16.67 -- 10.86 0.004 **
Seemed like a gratifying experience 28.81 33.33 -- 0.93 0.63
Help address elder abuse cases in professional work 59.32 91.67 100 5.70 0.06
Professional networking opportunities 30.51 41.67 -- 1.52 0.47
Other 13.56 8.33 -- 0.54 0.76
Missing: 2
Reason for continued participation
Monetary compensation from MDT -- -- -- -- --
Requirement set by job/organization 66.1 16.67 -- 12.53 0.002 **
Gratifying experience 52.54 75 100 3.58 0.17
Improved job performance 44.07 33.33 -- 1.91 0.38
Professional networking opportunities 61.02 41.67 -- 4.15 0.13
Other 15.25 25 -- 1.09 0.58
Missing: 2
92
Discussion
The purpose of this study was to develop a better understanding of EA MDT members to
improve efforts to recruit, train, support, and retain members. Building on prior research based
on four EAFC in California, we surveyed EA MDT members across the U.S. on MDT case
review processes, impacts, and creation.
Surveys were sent to all team members of sites identified through previous surveys that
captured the prevalence of MDTs in the U.S. MDT members who responded represented a wide
range of elder abuse and MDT experience. The results from this study show that most members
come from social services, joined the team because of job requirements or needing assistance on
cases, and stayed because of the gratifying experience. Additionally, although EA MDTs are
largely thought of as hubs for interdisciplinary communication, these findings suggest that they
might also be hubs for communication between individuals with different educational
backgrounds. Members differ in terms of background, education, and elder abuse experience,
suggesting that training is needed when recruiting new members, particularly those who have no
experience with an elder abuse case prior to joining.
We found that most respondents are motivated to join teams due to job requirements and
a need for help with professional work. Respondents were motivated to stay on the MDT for the
same reasons, along with an additional reason: their participation is a gratifying experience. This
is consistent with previous findings that show EA MDT involvement has impacts beyond the
resolution of elder abuse cases, including improved interagency collaboration and increased
knowledge of elder abuse (Yonashiro-Cho et al., 2019). This finding highlights an important
personal impact of EA MDT work that can be used for policy advocacy and agency recruitment
efforts. Related to the previous discussion about educational differences, those with
93
undergraduate degrees responded the highest on all reasons for initial and continued
participation. One explanation for this could be that individuals with bachelor’s degrees work on
the front lines and are more motivated to seek out help on cases. Professional networking
opportunities might also be an alluring factor for individuals in the early stages of their education
and careers. These findings could be utilized by MDT coordinators in agency recruitment efforts
to increase participation rates.
In terms of the second domain, case process, the results show that the top priority in case
decision making was fairly aligned between MDT, agency, and member: client safety and
protection. Prior to this study, case priorities have not been well understood; it was just as likely
that teams prioritized legal prosecution, or client autonomy, among other priorities. This finding
begins to elucidate the general MDT case review process that is directed toward “client safety
and protection.” As this becomes more explicit it will be important to consider and debate the
role of client safety and protection as a target goal in policy, advocacy, or guidelines for forming
new teams. Findings also support the importance of client wishes in MDT decision making,
sometimes to the point where case decisions are adjusted. The role of client-centered decisions
should be noted for new MDT establishment and the improvement of existing MDTs. More
research is needed regarding the potential dissonance of client wishes and client safety; this
includes discussions of how to balance the wishes of clients who desire case outcome that is
against the best interest of their well-being, especially those who are vulnerable, including clients
with some level of cognitive dysfunction.
MDTs are a way of overcoming silos without changing organizational structure or
systems. Members represent their organizations and their professions. Respondents endorsed a
range of comfort levels with sharing disagreements with other team members. MDTs may offer a
94
way to overcome barriers for the cases reviewed and may serve to permeate the silos in which
services to older adults currently operate (Connolly, 2010; Yonashiro-Cho et al., 2019). At the
same time, conflict among the team’s perspectives has not been well studied, suggesting a new
potential area of research: identifying and working through conflict in making elder abuse case
decisions within an MDT.
For the third domain, results show that respondents rated their MDTs’ overall level of
success positively, and that they and their agency contribute to this success. This supports the
previous research that these teams are a worthwhile intervention (Anetzberger, 2011; Connolly,
2010; Navarro et al., 2013; Yonashiro-Cho et al., 2019). Although evaluation of effectiveness
from team members is consistently high, more research is needed to rigorously define expected
outcomes and quantify the effectiveness of elder abuse MDTs across the U.S. The most notable
finding from the Team Effectiveness Inventory—which generally showed positive results—
suggested that some teams do not have the support and resources they need to meet their goals.
This should be considered a priority for policy supporting the eradication of elder abuse.
Additionally, evaluations on the effectiveness of MDTs should consider that these teams are not
operating at their full potential, and that we could see a significant improvement in outcomes
with increased budgetary support.
The final domain of MDT creation holds valuable information for those seeking to
establish new MDTs. Based on these results, individuals looking to start new teams should
expect challenges, particularly in terms of funding acquisition, case acquisition, and agency
recruitment. The barrier of funding is documented and arises in this study multiple times;
existing and new EA MDTs in the U.S. need budgetary support (Connolly, 2010). The
prominence of agency recruitment as a barrier to MDT establishment makes the findings of this
95
study particularly relevant. Those seeking to establish teams should use these findings to assist in
strategies on how to initiate and maintain member participation. The barrier of case acquisition
requires further research but could arise from various factors. First, the MDT may be in a
geographic location that is unable to recognize or identify elder abuse. Individuals interested in
addressing elder abuse through MDT interventions should consider maximizing resources to
assist in areas that suggest the intervention will be utilized. Additionally, the individuals starting
the MDT may have trouble with establishing trust with agencies that would bring in caseloads.
Case presentation could be intimidating for members, or the task of case presentation may be
unreasonable for those experiencing high caseloads. Case presentation may not be a priority for
law enforcement agencies or APS. Future research is needed to understand how to navigate the
barrier of case acquisition.
Limitations
It is important to note that this study offers a specific perspective that has not been widely
captured: the perceptions and views of MDT members about their respective MDT. It is
important to recognize that participants are likely to provide high rates for their MDTs’ success
and effectiveness. More research is needed to evaluate the effectiveness of EA MDT
interventions, as well as the specific contextual factors: geographic, political, and cultural
context, contribute to how the teams are scored.
Conclusion
We researched EA MDT members across the U.S. to better understand their
backgrounds, their MDTs’ creation, case processes, successes, and impacts. Findings show that
members of MDTs likely work in social services and are diverse in educational background.
Most members joined an MDT because of work requirements and need for assistance on cases
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and remain on the MDT for an additional reason: the gratifying experience. Findings show a
heavy consideration of client wishes when determining appropriate action on cases, and that
most members consider their MDTs successful. Members noted difficulties establishing MDTs
due to a lack of funding and challenging member recruitment. The lessons learned in this study
can be used to bolster member recruitment and assist those looking to create new MDTs or
improve existing MDTs.

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CHAPTER 5: CONCLUSIONS
This dissertation aimed to develop a better understanding of Elder Abuse
Multidisciplinary Teams in the U.S. As elder abuse continues to devastate the lives of older
adults, the multidisciplinary team approach has garnered key research and policy interest. The
potential for elder abuse cases to overwhelm siloed professional front line workers has led to
increasing adoption of this model nationwide, yet variations and structures that have not been
well studied. Additionally, the EAFC model has been distinguished as a promising model for
MDT replication, and has been supported in philanthropic, policy, and academic arenas. This
dissertation contributes to a growing foundation of elder abuse intervention research. It offers
information that can help promote and guide existing teams, including their structure, practices,
and processes. Findings can also be applied to the creation of new teams.
Overview
Chapter II illustrated the landscape of MDTs across the U.S. and provided perspectives
from EA MDT affiliates. Previously, research had identified and surveyed 30 MDTs in the U.S.
and captured anecdotal evidence of the value of MDTs (Breckman & Solomon, 2015; Teaster et
al., 2005). This literature called attention to the lack of knowledge about EA MDT interventions
and provided a foundation on which to build more in-depth research. In policy advocacy and
replication efforts, reliable evidence from academic research is critical (Friedlaender & Winston,
2004; Tabak et al., 2015) Chapter II contributed to this evidence by providing systematic and
detailed data on the prevalence, geographic location, type of abuse addressed, auspice, barriers,
and impact of EA MDTs. Additionally, this chapter found support for earlier studies that noted
that MDTs had potential as effective interventions for elder abuse and positive influences on
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members. In the present study, more than 300 MDTs were identified; the majority were housed
in healthcare settings, but several different types of host agencies were identified.
Although perceptions of MDTs were positive on various metrics, lack of funding and low
agency engagement were identified as major barriers to function/improvement. Additional fiscal
support from philanthropic and/or government could bolster efforts against elder abuse through
this intervention. As MDTs continue to grow in popularity, findings from this chapter—
including broad support coupled with lack of dedicated resources—can be used to inform
advocacy and establishment efforts.
Chapter III categorized EA MDTs in the United States and identified a class of MDTs
that aligned with the Elder Abuse Forensic Center Model (Yonashiro-Cho et al., 2019). Previous
studies have identified core components of this model, as seen in the EAFC Conceptual Model
(Yonshiro-Cho et al., 2019). This intervention garnered policy interest in the Elder Justice Act of
2010, spurring an urgency to understand the EAFC model in a broader context. The ability to
identify and create an EAFC based on a validated framework will be critical if the funds
authorized in the EJA supporting Forensic Centers are appropriated. This chapter provided a
clearer understanding of how the EAFC model applies and relates to other MDTs in the country.
This information may assist individuals establishing new MDTs, as well as policymakers looking
for ways to efficiently and effectively support efforts against elder abuse. This chapter also
showed that many MDTs in the U.S. function with some components of the EAFC model
already in place. Supporting these teams to become fully-fledged EAFCs may be a more efficient
use of funds than establishing new EAFCs. This chapter developed a more nuanced
understanding of MDTs in the U.S., in addition to the EAFC model as it applies to those MDTs.
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Chapter IV provided data from MDT members, an understudied and critical element of
team structure and operation. Previous research on EA MDTs most often surveyed the key
informant or coordinator of the MDT and had not captured information about team members.
Additionally, in Chapter III, agency participation was identified as a major barrier to MDT
function and improvement. Chapter IV builds a more detailed understanding of members’ elder
abuse professional experience, motivations, perceptions of the case review process, and
perspectives on establishing new MDTs. Findings showing that respondents join teams for help
on complex cases and professional networking opportunities could be used by coordinators to
recruit agencies to participate. Results confirming the need for funding support and resources, in
addition to highly rated perceived effectiveness scores can be taken to policymakers to advocate
for MDT support. This chapter provides the first empirical evidence from team members
nationwide about MDT participants, case processes, success measurement, and MDT
establishment, helping fill a gap in elder abuse intervention research (Ploeg, Fear, & Hutchison
et al., 2009).
Applications
This research holds potentially valuable lessons for other efforts related to human health
and wellness. In addition to policy and elder abuse-specific applications, these findings provide a
useful framework for approaching research about multidisciplinary teams in other fields,
specifically regarding characteristics and structures, functioning, and effectiveness.
First, these findings contribute to a growing support for multidisciplinary team efforts to
address elder abuse in policy and professional practice. Kingdon’s “three streams” policy
theory—which posits that policy change occurs with the alignment of problem, politics, and
policies—is particularly relevant for this dissertation (Kingdon, 1984). Although the elder abuse
100
field took advantage of a policy window of opportunity with the enactment of the Elder Justice
Act in 2010, a decade has passed without actionable steps taken or funds appropriated by
Congress. Since then, efforts have been made to build knowledge on the “Forensic Centers”
specified in the legislation. The related contribution of this dissertation is two-fold: it will assist
in advocacy efforts to bring attention to EAFCs/EA MDTs, and prepare the field for effective
implementation if the EJA provisions are acted upon. This dissertation can function similarly on
a state level: states that have mandated MDTs could use these findings to build more effective
teams. Advocacy efforts could use this information to initiate efforts to address elder abuse, or
incorporate EAFCs/EA MDTs into existing efforts, such as Master Plans for Aging seen in
Colorado, Connecticut, Minnesota, and California (in progress). On a local level, this dissertation
can serve community leaders and professionals in need of support for cases of elder abuse by
providing an evidence base that supports the use of MDTs. This dissertation provided valuable
empirical evidence for use when the policy window reopens for elder abuse interventions.
The multidisciplinary team approach to health and wellness is not a novel concept;
hospital care, primary care, and public health spheres (in the UK) have recognized their value
(Dion, 2004; Saint-Pierre, Herskovic, & Sepulveda, 2017; Wood, Williams, Billings, & Johnson,
2019). MDTs have been used to assist several domains that involve complex service delivery:
palliative care, cancer care, diabetic care, psychiatry, and child abuse, among others (Hussain,
Almarzooq, & Alrayes, 2019; Leigh, 1987; Lalayants & Epstein, 2005; Wiley et al., 2015).
Overall these teams in healthcare settings are rated positively on patient outcomes and
professional satisfaction, although this research also notes the difficulty in establishing a direct
connection between improved outcomes and the team itself (Coory et al., 2008; Dyson et al.,
2013). Knowledge about structural variations and standards for MDTs in these other domains
101
remains sparse, with only a few studies recognizing potential benefits and challenges of
individual teams (Breland et al., 2019; Lalayants & Epstein, 2005; Wood et al., 2019). The utility
of information on EA MDT prevalence, perceptions of field-relevant professionals, team
classification, and team member perspectives could guide and spur other fields to address similar
gaps. This dissertation provides a comprehensive and systematic examination of MDTs., which
can help inform multidisciplinary efforts in other health and wellness arenas.
A Connection to Implementation Science
Implementation science—defined as “the process of putting to use or integrating
evidence-based interventions within a setting”—provides useful concepts for understanding the
findings in this dissertation (Rabin & Brownson, 2017). Chapter 1 captured information on
MDTs in the U.S., providing important details on the broad geographic and political context for
understanding the EAFC model and MDT models overall (Fixsen, Naoom, Blase, Friedman, &
Wallace, 2005). This can assist the implementation process by garnering the support of
policymakers and stakeholders with evidence-based research. Chapter 2 identified common
characteristics of the flagship EAFC model among MDTs in the U.S. This helped identify key
components of this model and provided clarity to researchers and EAFC/MDT coordinators on
how this model might exist in other settings (Fixsen et al, 2005). These findings can assist the
implementation process by providing a foundation on which to build an EAFC, which can then
be modified to meet specific community needs. Chapter 3 focused on team members of MDTs in
the U.S., which provided information about the operators of this intervention. This research
assists with implementation by giving MDT leaders a better understanding of what to expect
from participating members, and how to recruit and retain these members. Findings in this
dissertation improved our understanding of a the EAFC model and EA MDT models across the
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country, descriptive information which research suggests can lead to smoother implementation in
various contexts (Bauman, Stein, & Ireys, 1991; Dale, Baker, & Racine, 2002)
Limitations
Obtaining adequate response rates for each stage of data collection was a challenge,
particularly in Chapter IV. Significant efforts were made to distribute surveys effectively and
follow-up with potential respondents. A longer collection period combined with a similar
extensive follow-up and higher respondent commitment might capture more information.
The studies in this dissertation relied on subjective responses from elder abuse
professionals, EA MDT coordinators, and EA MDT members. Therefore, the findings in this
dissertation on MDT success and effectiveness should be added to using program evaluation
studies, which are lacking in this field.
Future Research
Future research should explore the relationship between EA MDTs and improvements in
elder abuse case outcomes. Thus far, this connection is unclear and is a barrier to building a case
for EA interventions. Current research on the EAFC model has noted higher prosecution and
conservatorship rates compared to traditional APS responses, but these outcomes have not been
compared to semi-EAFCs or non-EAFCs in the U.S. (Gassoumis et al., 2015; Navarro et al.,
2013). A significant challenge related to this goal is data collection: some (if not most)
underfunded MDTs may not have the administrative capacity to track case outcomes over time.
Furthermore, this area of research requires a nuanced understanding of desirable elder abuse case
outcomes. Future research should explore organizational values of MDTs (EAFCs, Semi-
EAFCs, and Non-EAFCs alike), particularly as it relates to success measurement and desired
outcomes.
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Relatedly, future research should rigorously evaluate the cost effectiveness of MDTs.
Practical and robust implementation of an intervention is bolstered by the availability of cost
data, which is currently lacking in EA intervention research (Feldstein & Glasgow, 2003). This
cost data can be used to promote action on current elder abuse legislation and support the
economic value of EA MDT interventions to key decision makers in policy, healthcare, legal,
and social services fields. In addition to evaluating the costs of operations and savings potential
of MDTs/EAFCs, research should also explore differences in cost by geographic region, case
type/load, and team composition.
Conclusion
In the past decades, EA MDTs have been the flagship intervention for complex elder
abuse cases. This dissertation provided novel findings on EA MDTs in the U.S., particularly the
high-powered EAFC model that has garnered a place in federal legislation. As recognition of
elder abuse issues grows, the field must be prepared to offer a substantive evidence-based
foundation for the contextualization and implementation of effective MDT models. The findings
in this dissertation contribute significantly to this foundation.

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APPENDIX A: CHAPTER 2 INSTRUMENT
What type of organization/agency do you work for?
m Adult Protective Services
m Law Enforcement
m District Attorney or similar (e.g., City Attorney, Commonwealth's Attorney)
m Legal Services
m Healthcare
m Family Violence
m Social Services Agency (other than APS)
m Clergy
m Financial Institution
m Other Governmental Agency (please specify) ____________________
m Other (please specify) ____________________

What is the primary state in which you perform your professional duties?

For this survey, we are interested in finding out about various types of elder abuse multidisciplinary teams
and other elder abuse networks. We are interested in multidisciplinary teams (MDTs) that engage in case
review for elder abuse cases as well as any other multidisciplinary teams or networks that address elder
abuse.In this survey, you will be asked to identify MDTs you are familiar with. You will also be asked to
identify Networks you are familiar with. For each MDT you identify, you will be asked a set of questions
specific to that MDT. For each Network you identify, you will be asked a set of questions specific to that
Network. Here are some definitions to help you understand what we are looking for.
Elder Abuse: Abuse, neglect, or financial exploitation of an elder. The abuse could be physical abuse,
sexual abuse, or psychological/emotional/mental abuse.
Elder Abuse Multidisciplinary Team (MDT): A team that is comprised of professionals from a variety of
disciplines working together ON AN ONGOING BASIS TO COMBAT ELDER ABUSE.
Network: Broadly defined as any group of professionals involved in addressing elder abuse. These could
be highly structured or more unstructured, and would include groups such as community collaboratives,
coalitions, consortia, triads, task forces, and many other models.
Case Review: Reviewing and addressing individual cases of elder abuse, with a goal of providing action
steps and recommendations specific to that case.

How long have you worked on elder abuse issues?
m Less than 1 year
m 2-5 years
m 6-10 years
m 11+ years

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Are you aware of any elder abuse MDTs in your area that engage in case review?
m Yes
m No

Are you aware of any other elder abuse networks in your area?
m Yes
m No

Display This Question:
If Are you aware of any MDTs in your area that engage in case review? Yes Is Selected
For each elder abuse MDTs that engages in case review in your area, please list the title of the team (or
the sponsoring agency, if there is no official team title). Your response here will be referenced later in the
survey when we ask you for more information about each MDT.Note: Complete one box for each MDT
you're aware of. Leave all other boxes blank.

Display This Question:
If Are you aware of any other elder abuse networks in your area? Yes Is Selected
For every other elder abuse network in your area, please list the title of the network (or the sponsoring
agency, if there is no official network title). Your response here will be referenced later in the survey
when we ask you for more information about each network.Note: Complete one box for each network
you're aware of. Leave all other boxes blank. Do not include networks you've already listed in the MDT
question.

Now we would like to ask you some questions specifically about the MDT you identified.

Is [MDT name] housed within or affiliated with a host organization/agency?
m Yes (please specify) ____________________
m No

Who would be the best person for us to contact about [MDT name] (if known)?

If you know the physical address for this MDT, please provide below:
m ____________
m N/A - no physical address exists for this MDT

If you know the phone number for this MDT, please provide below:
m ____________________
m N/A - no phone number exists for this MDT

If you know the website for this MDT, please provide below:
m _______________
m N/A - no website exists for this MDT

Have you ever attended a meeting of this MDT?
m Yes
m No
Condition: No Is Selected. Skip To: Have you ever been asked to attend th....
112

How would you describe your attendance in this MDT?
m Only attended once
m Attended rarely
m Attended occasionally
m Attended routinely
m Frequently

When was the last time you attended a meeting of this MDT (${lm://Field/1})?
m Within the last year
m 1-3 years ago
m More than 3 years ago

What was your primary role in attending meetings of this MDT? (mark all that apply)
q Observer
q Team Member
q Presenter
q Coordinator/Administrator/Facilitator

How would you classify this MDT? (select all that apply)
q General MDT
q Financial Abuse Specialist Team (FAST)
q Elder Abuse Forensic Center (EAFC)
q Fatality Review Team
q Hospital-based MDT
q Other (please specify) ____________________

What types of cases does this MDT see? (mark all that apply)
q Physical abuse
q Sexual abuse
q Psychological/emotional/mental abuse
q Financial abuse/exploitation
q Neglect by other
q Self-neglect
q Other (please specify) ____________________

Of these types of abuse, which type of case does this MDT see the MOST?
m Physical abuse
m Sexual abuse
m Psychological/emotional/mental abuse
m Financial abuse/exploitation
m Neglect by other
m Self-neglect
m Other (please specify) ____________________

Has participating in this MDT changed how you address elder abuse cases?
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m Not at all (1)
m 2
m 3
m 4
m A lot (5)

To what extent do you believe this MDT changes outcomes for elder abuse cases? Very positively
m Positively
m Neither positively nor negatively
m Negatively
m Very negatively

Do you believe that this MDT reduces the occurrence of elder abuse?
m Yes
m No

Which of the following describe major barriers to this MDT's success? (check up to 3 options)
q Funding/resources
q Team organization
q Team leadership
q Time commitment
q Transportation to MDT meeting
q Difficulty identifying appropriate cases
q Member engagement (members who refuse to be actively involved)
q Agency engagement (organizations that refuse to participate)
q Perceived inability to share information (due to perceived legal restrains)
q Other (please specify) ____________________
q No major barriers exist for this MDT

Display This Question:
If Have you ever attended a meeting with this MDT? No Is Selected
Have you ever been asked to attend this MDT?
m Yes
m No

114
Display This Question:
If Have you ever attended a meeting with this MDT? No Is Selected
If you made the decision not to attend a meeting of this MDT, which of the following best describes the
reason? (check all that apply)
q I would like to attend, but I am too busy
q My organization/employer does not provide me with time to participate
q My organization/employer does not permit me to attend
q Not a good use of time
q Not relevant to the work that I do
q Hostile/disagreeable relationships with one or more MDT members
q The MDT members can be intimidating
q Disorganization within the MDT
q Other (please specify) ____________________

Display This Question:
If Have you ever attended a meeting with this MDT? No Is Selected
Now we would like to ask you some questions specifically about the network you identified.

Is ${lm://Field/1} housed within or affiliated with a host organization/agency?
m Yes (please specify) ____________________
m No

Who would be the best person for us to contact about ${lm://Field/1} (if known)?

If you know the physical address for this Network, please provide below:
m ____________
m N/A - no physical address exists for this Network

If you know the phone number for this Network, please provide below:
m ____________________
m N/A - no phone number exists for this Network

If you know the website for this Network, please provide below:
m _______________
m N/A - no website exists for this Network

115
Have you participated in any activities of this network?
m Yes
m No
What types of cases does this network (${lm://Field/1}) deal with? (mark all that apply)
q Physical abuse
q Sexual abuse
q Psychological/emotional/mental abuse
q Financial abuse/exploitation
q Neglect
q Self-neglect
q Other (please specify) ____________________

Of these types of abuse, which type of case does this network (${lm://Field/1}) deal with the MOST?
m Physical abuse
m Sexual abuse
m Psychological/emotional/mental abuse
m Financial abuse/exploitation
m Neglect
m Self-neglect
m Other (please specify) ____________________

How has participating in this network changed your approach to your job?
m Very positively affected
m Positively affected
m Neither positively nor negatively affected
m Negatively affected
m Very negatively affected

Do you believe that this MDT improves outcomes for cases of elder abuse?
m Yes
m No

Do you believe that this MDT reduces the occurrence of elder abuse?
m Yes
m No

If you could raise three comments, suggestions, or questions regarding elder abuse MDTs in general, what
would they be?

116
APPENDIX B: CHAPTER 3 INSTRUMENT
1. Is [MDT name] still functioning?
❏ Yes
❏ No
If “No” if chosen:
N1. How long as it been since the last time the MDT was convened?
❏ Less than 1 year
❏ 1-2 years
❏ 2-5 years
❏ 5-10 years
❏ More than 10 years
N2. Why is this MDT no longer functioning (choose all that apply)?
❏ Lack of funding
❏ Lack of participation from MDT members
❏ Absence of cohesion/effective cooperation between MDT members
❏ Lack of cases being referred
❏ Lack of support from parent organizations
❏ Lapse in leadership
❏ Inability to share information between organizations
❏ Perceived inability to help resolve cases
❏ Other (please specify):_______
N3. Once we know more about MDTs that are still functioning, we may reach out in the future to contact
you. To help us in our contact efforts, please list the best phone number to reach you: ___

If “Yes” is chosen:
Y1. Name of MDT:________
City:
Your Name:
Email address:
Contact phone number:

Y2. Matrix #1: Please help us ensure that we have the best contact information for you. Please provide the
best contact information to reach you, if different from the information listed above:
Best Contact Info Information Above is
Correct
MDT Name
❏ _____ ❏
Contact Name
❏ _____

❏
Contact Phone
❏ _____

❏
Rough Location (City,
State)
❏ _____ ❏
Street Address
❏ _____ ❏
Mailing Address
❏ _____ ❏
Website
❏ _____ ❏
117

Y3. We are helping to refine a directory of MDTs compiled by the U.S. Department of Justice’s
MDT Technical Assistance Center, which will be posted on their website
(https://www.justice.gov/elderjustice/mdt-tac). Please let us know what information about your
MDT we can pass on for inclusion in the directory.

Do Not Include Include Information
You Currently Have
Corrected Contact
Information:
MDT Name
❏ ❏ ❏ _______
Contact Name
❏

❏ ❏ _______
Contact Phone
❏

❏ ❏ _______

Rough Location (City,
State)
❏ ❏ ❏ _______
Street Address
❏ ❏ ❏ _______
Mailing Address
❏ ❏ ❏ _______
Website
❏ ❏ ❏ _______

Structure
2. Does your MDT have a mission statement (i.e., core statement of purpose)? If yes, please paste it here:
______________

Coordination/Program Management
3. Does your MDT have any of the following:
❏ Dedicated program staff (paid)
❏ Dedicated program staff (volunteer: does not include MDT members from participating agencies)
❏ Paid consultants
❏ None of the above

4. List anyone with a leadership or organizational role in your MDT. This could include people paid by
your MDT as well as core team members who play a more substantial role in the team’s leadership or
organization? You can either use the person’s name, initials, or a pseudonym when listing them – the
important thing is that you know who each line represents.
Name
Please select this individual’s principal role
with the MDT:
What is this person responsible for? (Check
all that apply)
________
❏ Paid staff
❏ A paid consultant (not paid by the
MDT)
❏ A volunteer (not paid by the MDT)who
is not a member of a participating
agency
❏ A volunteer who is a member of
participating agency (please specify
which agency)
❏ Executive leadership (such as, Director)
❏ Schedules meetings
❏ Coordinates with presenters
❏ Moderates MDT meetings
❏ Decides which cases to review
________

[same as above] [same as above]
118
________

[same as above] [same as above]

5. To be asked if any of the roles are not chosen for any of the identified people: You haven’t
identified anyone for [select category], is there someone at your MDT who has this role? If so please go
back, if not please continue.

6a. You identified multiple people as being responsible for [name of category]. How is this
responsibility divided among these multiple people? (question will be repeated for all responsibility
categories where multiple people are identified)
❏ They share the role concurrently
❏ They alternate

6b. If “alternate” is chosen: Generally, how often do they alternate?
❏ Every meeting
❏ Once a month
❏ Quarterly (four times a year)
❏ Once a year
❏ Other (please describe): ___________

7. Are there other people (not listed above) who fall into the following categories (check all that apply)
❏ Paid staff
❏ Paid consultants
❏ Volunteer (who is not a member of participating agency)

Team Composition:
8. Please list each agency that participate in your MDT, and answer the five questions for each agency.
Agenc
y
(Descriptive)
Agency’s
relationship has
been formalized
through written
agreement
(MOU, MOA,
etc.)
(Categorization)
Agency provides
professional
services to your
MDT
(Descriptive)
Agency
provides
monetary
funding to your
MDT
(Categorization
) Agency
provides cases
for MDT
review
How often
does this
agency attend
meetings in
this MDT?
______
❏ Yes
❏ No
❏ Not sure
❏ Yes
❏ No
❏ Not sure
❏ Yes
❏ No
❏ Not sure
❏ Yes
❏ No
❏ Not sure
❏ Never
❏ Rarely
(less than
1/3 of the
time)
❏ Sometime
s (1/3 to
2/3 of the
time)
❏ Often
(over 2/3
119

9. (Categorization) What professions participate in [MDT name]?
□ APS
□ Physician
of the
time)
❏ Always
______
❏ [same] ❏ [same] ❏ [same] ❏ [same] ❏ [same]
______
❏ [same] ❏ [same] ❏ [same] ❏ [same] ❏ [same]
MATRIX CONTINUED
Agenc
y
When this
agency attends
an MDT
meeting, how
many
individuals
from this
agency are
present, on
average?
When this agency
sends someone, is
it usually the same
person/people, or
does it change?
Rate the level of
participation of
this agency’s
representative(s
) during MDT
case review
meetings.
Rate this
agency’s
overall level of
participation
(outside of
normal meeting
times) in MDT
cases.

______
❏ 1-10
(dropdown
)
❏ More than
10
❏ Same
person/people
❏ Person/peopl
e change(s)
❏ Present and
fully
engaged in
the process,
often
adding
comments
and other
input when
appropriate
❏ Present and
partially
engaged in
the process,
rarely
adding
comments
when
appropriate
❏ Present
(attends the
meeting),
but
otherwise
not
engaged

❏ Fully
engaged in
cases,
when
appropriate
and/or
requested
❏ Partially
engaged in
cases,
when
appropriate
and/or
requested
❏ Not
engaged in
cases, even
when
appropriate
and/or
requested

______
❏ [same] ❏ [same] ❏ [same] ❏ [same]

______
❏ [same] ❏ [same] ❏ [same] ❏ [same]

120
□ Other Medical Personnel (Nurse, PA)
□ Prosecuting Attorney
□ Victim Advocate
□ Law Enforcement
□ Public Guardian / Conservator
□ LTC Ombudsman
□ Psychologist
□ Mental Health Services
□ Senior Legal Aid
□ Developmental Disability Services
□ Coroner/Medical Examiner
□ Community Care Licensing
□ Intimate Partner Violence Services
□ Financial Industry Representatives/Personnel
□ Other: _______

10. (Categorization) Do participants in your MDT receive formal training to join the MDT? This can
include, but is not limited to: how to participate as a team member, procedures/systems within the MDT,
and education on elder abuse.
❏ Yes
❏ No

11. (Descriptive – move to survey 3) Are there students, interns, or fellows who attend meetings?
❏ Yes
❏ No

12. (Descriptive – move to survey 3) If yes, do these people receive formal training?
❏ Yes
❏ No

Geography:
13. (Descriptive) What community/catchment area does your MDT serve? (please choose one)
❏ Single county:
❏ Multiple counties:
❏ Single city:
❏ Multiple cities:
❏ Tribal area:

14. (Descriptive) Would you best describe this service area as primarily rural, or urban?
❏ Primarily rural
❏ Primarily urban
❏ Combination of rural and urban

121
15. (Descriptive) How do team members participate in MDT meetings? (Choose all that apply)
❏ In person
❏ By telephone conference line
❏ By video conference line

16. (Descriptive) How do presenters (who are not part of the team) participate in MDT meetings?
(Choose all that apply)
❏ In person
❏ By telephone conference line
❏ By video conference line

Client Population:
17. (Descriptive) Does your MDT target and/or specialize in a specific population?
❏ No specific target population, everyone in catchment area is served equally
❏ Individuals with intellectual/developmental disabilities
❏ Individuals with significant physical disability/limited mobility
❏ Cognitively impaired individuals
❏ Older adults over 60
❏ Native/tribal populations (such as Native Americans, Alaskan/Hawaiian natives)
❏ African Americans
❏ Latinos/Hispanics
❏ Asians/Pacific Islanders
❏ None
❏ Other (please specify)
17b. Is your MDT limited to the population specified above (i.e. your MDT does not typically serve
individuals outside of this population)?
❏ Yes
❏ No (please list any other specific population this MDT serves): ________
❏ Don’t know

18. (Descriptive) Please estimate the portion of clients you serve who demonstrate a degree of cognitive
impairment?
❏ None
❏ Some (less than 50%)
❏ Most (more than 50%)
❏ All
❏ Don’t know

19. (Descriptive – move to survey 3) Please estimate the racial/ethnic composition of the clients you
serve? Please estimate the percentage of your clients that come from each racial/ethnic group.
• Native/tribal populations ___%
• African Americans ___%
• Latinos/Hispanics ___%
122
• Asians/Pacific Islanders ___%
• White ___%
• Other (please specify) ___%
Logistics
Team Meetings:
20. (Categorization) How often are meetings held? (Identify best answer)
❏ Weekly
❏ Once every two weeks
❏ Once a month
❏ Quarterly (four times a year)
❏ Once a year
❏ Check here if meetings are held periodically, with no regular meeting times
❏ Other

21. (Descriptive) Approximately how long do meetings last?
❏ Under 60 minutes
❏ 60-90 minutes
❏ Over 90 minutes

22. (Descriptive) On average, how many new cases are reviewed each meeting?
❏ 1-2
❏ 3-5
❏ 6-10
❏ 11-20
❏ Over 20

23. (Descriptive) On average, how many new cases are reviewed per year?
❏ 1-10
❏ 11-30
❏ 31-50
❏ 51-100
❏ Over 100

24. (Categorization) Please estimate the average amount of time in each meeting that is allocated to:
• New case presentation ___%
• Follow-up on previously presented cases ___%
• Providing education to team members/meeting attendees ___%
• Networking ___%
• Other activities ___%
o Please specify what these activities are:

Recommendations:
Note, two types:
123
-Recommendations to one or more team members
-Recommendations to the presenter

25. Following case presentation, does your MDT make any formal recommendations for the case?
❏ Never
❏ Rarely
❏ (Sometimes)
❏ Often
❏ Always

26. If respondents choose anything except “never”: Are those recommendations only for action by the
case presenter, only for action by non-presenting team members, or both?
❏ Case presenter
❏ Non-presenting team members
❏ Both

27. This matrix will be displayed with one or both columns, depending on the answer to the previous
question:
Recommendations for action
by the case presenter
Recommendations for action
by non-presenting members of
the team
Is a summarized list of
recommendations created at the
end of the case presentation?
❏ Never
❏ Rarely
❏ Often
❏ Always
❏ Never
❏ Rarely
❏ Often
❏ Always
Who, if anyone, track progress
on team recommendations?
-No one tracks
-[Drop down list of previous
leader names]
-Other (please specify)
-No one tracks
-[Drop down list of previous
leader names]
-Other (please specify)
Which of the following best
describes the tracking of
progress on team
recommendations?
(categorization)
-Presenter is asked about the
progress of the recommendation
-Presenter is encouraged to
complete any incomplete
recommendations
-Presenter is provided additional
resources to assist in the
completion of recommendations
-Presenter is tasked with a new
course of action in place of
incomplete recommendations
-Non-presenting member is
asked about the progress of the
recommendation
-Non-presenting member is
encouraged to complete any
incomplete recommendations
-Non-presenting member is
provided additional resources to
assist in the completion of
recommendations
- Non-presenting member is
tasked with a new course of
action in place of incomplete
recommendations

Are there any additional
methods of tracking
recommendations performed by
your team?
-Free entry -Free entry
124
In the event of
conflict/disagreement among
team members regarding a case
recommendation, which best
describes the course of action
taken by your MDT?
-The MDT coordinator takes
into consideration all accounts
and makes an executive decision
-The MDT members debate the
recommendation until a viable
compromise has been reached
-The case recommendation is
suspended, to be debated at a
later meeting date
-Other (please specify)
-The MDT coordinator takes
into consideration all accounts
and makes an executive decision
-The MDT members debate the
recommendation until a viable
compromise has been reached
-The case recommendation is
suspended, to be debated at a
later meeting date.
-Other (please specify)

27b. Please estimate how many times an average case is brought back to the team for re-review/case
update?
❏ 0
❏ 1
❏ 2-3
❏ More than 3

Day-to-day Operations:
28. (Descriptive) Is there an official protocol regarding who can refer clients to your MDT?
❏ Yes
❏ No

29. (Descriptive) Is there a formalized document laying out these requirements?
❏ Yes
❏ No

30. (Categorization) What types of cases are accepted?
❏ Self-neglect
❏ Hoarding
❏ Neglect
❏ Abandonment
❏ Financial exploitation
❏ Physical abuse
❏ Sexual abuse
❏ Emotional/Psychological abuse

Costs:
31. (Descriptive) Approximately how much does [MDT name] spend on direct budgeted operating costs,
including salaries from paid staff?
❏ No budget
❏ Less than $500/month ($6000/year)
❏ $500-2000/month ($6000-$24,000 /year)
❏ $2000-$5000/month ($24,000-$60,000/year)
❏ $5000-$9000/month ($60,000-$108,000)
125
❏ Over $9000/month ($108,000/year)

32. What resources are donated to your MDT or provided in-kind by a participating agency or
organization?
❏ Meeting space/rent
❏ Office space/rent
❏ Support staff/administrative staff
❏ Office supplies
❏ Recurring technology costs (such as internet, phone costs, teleconferencing costs, service
contracts)

32b. If known, please provide the estimated value for each of the in-kind donations listed above.
❏ Meeting space/rent: ______
❏ Don’t know
❏ Office space/rent: ______
❏ Don’t know
❏ Support staff/administrative staff: ______
❏ Don’t know
❏ Office supplies: ______
❏ Don’t know
❏ Recurring technology costs (such as internet, phone costs, teleconferencing costs, service
contracts) : ______
❏ Don’t know

33. (Descriptive) Estimate the value of “in-kind” staff time provided by MDT member agencies based on
the amount of time spent by team members, both in and out of team meetings (include operational costs):
_______

Funding:
34. (Descriptive) Not asked if “no budget” is reported: From which of the following does your MDT
receive the most funding?
❏ Federal funds
❏ State funds
❏ Local government funds
❏ Private foundation/charity funds
❏ Other (please specify)

Needs:
35. (Descriptive) What resources do you still need?
❏ Funds for staffing
❏ Physical infrastructure
❏ Technology
❏ Office supplies
126
❏ Other (please specify)

Services
Activities:
36. (Categorization) Which of the following case-related activities do MDT members engage in (outside
of normal MDT meeting times) due to the case being presented to the team? (check all that apply)
❏ Obtaining client/perpetrator records (such as bank statements, criminal records)
❏ Review of client records (such as medical records, legal documents)
❏ Direct services to clients (such as mental health counseling, estate planning)
❏ Home visit
❏ Capacity assessment
❏ Interviews with third parties
❏ Case documentation (such as report writing)
❏ Communication between agencies
❏ Other (please specify) ______

37. Apart from reviewing cases, what activities does your MDT engage in outside of normal meeting
times?
❏ Facilitating the flow of documents and other information between agencies/organizations
❏ Sharing best practices for investigatory approaches between agencies* (ripple effect)
❏ Education to the public
❏ Education to professional groups
❏ Retreats/workshops targeted to MDT members
❏ Policy/public systems changes
❏ Data collection
❏ Other (please specify) ______

38. Does your MDT have access to someone who can perform formal capacity assessments that could be
used in a courtroom (criminal, civil, probate)?
❏ Geriatrician
❏ Psychiatrist
❏ Other Physician (specify specialty)
❏ Psychologist
❏ Other (please specify)
*Later downstream: Approximately how many assessments are conducted over the course of a year?
Table with physician, psychologist, neuropsychologist

[FOR SURVEY 4, targeting individual team members] In the course of managing the case, are
individuals from your agency required to make a judgment about the client’s capacity to refuse services?

39. (Descriptive) What services are provided to clients, either by MDT staff or paid consultants (direct
services), or by participating agencies (indirect services)? (only if “direct services” is checked in previous
question)
127
(DESCRIPTIVE) Provided by MDT staff/paid
consultants
Provided by MDT members
from participating agencies

❏ ❏
Medical (such as prescribing
medication, providing
treatment)
❏

❏
Psychological
❏ ❏
Case Management
❏ ❏
Legal (such as estate planning,
quit claim services, restraining
orders)
❏ ❏
Financial
❏ ❏
Housing services (such as long
term housing, emergency
housing and placement,
homelessness)
❏ ❏
Other Free entry Free entry
Distinction: if there are multiple agencies involved

Case Tracking:
40. Does your MDT start a case file (paper or electronic) for each case presented?
❏ Always
❏ Usually
❏ Rarely
❏ Never

41. (Descriptive) What system is used to collect information about cases? (Check all that apply)
❏ Paper-based systems
❏ Computerized spreadsheets (such as Microsoft Excel)
❏ Computerized database (such as Microsoft Access)
❏ Web/cloud-based data system
❏ Other data system (please specify)
❏ No data system is used

42. *Skip if answer was “never” to 40 Are these files updated with new information about each case?
❏ Always
❏ Usually
❏ Rarely
❏ Never

43. (Descriptive) What system is used to track information about cases over time? (Check all that apply)
❏ Paper-based systems
❏ Computerized spreadsheets (such as Microsoft Excel)
❏ Computerized database (such as Microsoft Access)
❏ Web/cloud-based data system
128
❏ Other data system (please specify)
❏ No data system is used

44. (Descriptive) What type of information is routinely collected about cases presented to your MDT?
❏ Demographic
❏ Financial
❏ Psychological assessment
❏ Medical assessment
❏ Personal statements from client
❏ Case narrative
❏ Case timeline
❏ Personal statements from witnesses/alleged abusers
❏ Other (please specify):___

45. (Descriptive) Is this information analyzed or used for any other purposes besides case review (please
specify what this purpose is)?
❏ Yes (________)
❏ No

Outcomes
46a. What does your team consider indicators of success? Which are monitored over time?
(Descriptive) Considered
indicator of team success? What
do people expect to receive
when they bring a case to your
team? (check all that apply)
(Categorization) Is this outcome
monitored/tracked over time?
(check all that apply)
Improvement in client health
status
❏ ❏
Improvement in client mental
health status
❏ ❏
Improvement in client quality of
life
❏ ❏
Guardianship/Conservatorship
❏ ❏
Legal services (counsel, aid)
provided
❏ ❏
Restitution
❏ ❏
Prosecution
❏ ❏
Preventing recurrence of
abuse/victimization
❏ ❏
Other
❏ ❏

46b. When does the MDT consider a case to be closed (the MDT stops tracking the case)?
❏ If the client dies
❏ If case is closed by all member agencies
❏ If all desired outcomes are achieved
129
❏ Other (please specify): ____

History:
47. (Descriptive) What year was [MDT name] established?

48. (Descriptive, likely survey 3?) What steps were involved in the establishment of your MDT? (choose
all that apply)
❏ Performed needs assessment of the community
❏ Conducted strategic planning sessions
❏ Identified potential participating agencies
❏ Applied for funding
❏ Other (please specify)
❏ Don’t know

49. Is your MDT based on or a replication of an existing MDT?
❏ Yes
❏ No
❏ Don’t know

50. If yes: Which model was your MDT based on? (free entry)

51. Are you aware of any resources that would guide someone trying to establish an MDT similar to
yours? (free entry)

52. Has the MDT had significant changes to its structure, function since its inception?
❏ Yes (please provide brief description)
❏ No
❏ Don’t know
Barriers:
53. (Descriptive) What barriers to program operation or growth have you encountered?
q Funding/resources
q Team organization
q Team leadership
q Team members or presenters unable/unwilling to commit adequate time to meetings
q Access to MDT meeting (transportation, or capability to join meeting remotely)
q Difficulty identifying cases appropriate for presentation
q Member engagement (members who refuse to be actively involved)
q Agency engagement (organizations that refuse to participate)
q Perceived inability to share information (due to perceived legal constraints)
q Lack of cases
q Other (please specify) ____________________
q No major barriers exist for this MDT

54. (Descriptive) Are there specific laws or policies that have created barriers to the team’s work?
❏ Yes (please specify)
130
❏ No

55. (Descriptive) Are there specific laws or policies that have been helpful/supportive to the team?
❏ Yes (please specify)
❏ No

56. (Descriptive) What promising practices, if any, have arisen from your MDT? (free entry)

57. Please rate your MDT as you respond to the following statements and questions. Although the
statements below may not apply to every single member of your MDT, please choose responses that
capture your MDT as a whole.
Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
In general, members of this MDT interact
cooperatively with people outside of their
professional discipline

1

2

3

4

5
In general, members of this MDT communicate
effectively

1

2

3

4

5
In general, members of this MDT respect and
appreciate each other’s roles and expertise

1

2

3

4

5

In general, members of this MDT feel safe
bringing up concerns about roles and
responsibilities on cases

1

2

3

4

5
In general, MDT members’ thoughts and opinions
are heard and considered

1

2

3

4

5

In general, members of the MDT are active
listeners and pay close attention to the
contributions of other members of the MDT

1

2

3

4

5
In general, members of this MDT can tolerate and
are willing to work through conflict

1

2

3

4

5

This MDT generally promotes camaraderie among
team members (for example, by paying attention to
important personal or professional events,
celebrating achievements, acknowledging
milestones)

1

2

3

4

5

131
APPENDIX C: FIT STATISTICS FOR LCA

Table 3.8. Fit Statistics for a Latent Class Analysis of EA MDTs
Number of Classes LL DF G_SQUARED AIC BIC CAIC ABIC ENTROPY
2 -526.51 4070 377.66 427.66 487.53 512.53 408.68 0.74
3 -510.26 4057 345.17 421.17 512.16 550.16 392.32 0.80
4 -497.46 4044 319.56 421.56 543.68 594.68 382.84 0.81
5 -485.28 4031 295.21 423.21 576.45 640.45 374.62 0.85
6 -475.67 4018 275.99 429.99 614.36 691.36 371.53 0.88
7 -466.56 4005 257.76 437.76 653.26 743.26 369.43 0.92
132
APPENDIX D: FIGURE 3.2. ILLUSTRATING RESPONSE PROBABILITIES FOR LCA
MODELS WITH 2, 3, & 4 CLASSES

133
APPENDIX E: MDT LIST BY NAME AND CATEGORY

List of MDTs in Each Latent Class (N =81)
EAFCs Semi-EAFC Non-EAFC
Hennepin County Adult Protection/Law Enforcement Team Columbia County I-Team No Name Provided
Rapid Response Expert Team Butler County Elder Safety Network Dependent Elder Abuse Review and Elder Death Review Team (DEAR/EDRT)
Adult Protection Team Standing Rock Elderly Protection Team So. SLC APS MDT
Los Angeles Elder Abuse Forensic Center Fond du Lac County I-team Aging and Independence Services & Law Enforcement Brown Bag
Orange County Elder Abuse Forensic Center York-Poquoson Adult MDT Social Services
Cuyahoga County Adult Protective Collaborative San Diego County Cross Regional MDT Grant Co. Interdisciplinary Team
Elder Abuse E-MDT Bronx Elder Abuse Multi Disciplinary Task Force Marinette County EAN Team
Will County Adult Protective Services M-Team (Multi-Disciplinary Team) South County MDT Wood County I-Team
Ulster County E-MDT Wyandotte County Crisis Response Consortium Onondaga County E-MDT
Elder & Vulnerable Adult Abuse Multidiscplinary Team Douglas County I Team No Name Provided
Law Enforcement Staffing MDT West Central Illinois MDT No Name Provided
Clinton County Financial Exploitation MDT Adults at Risk I-Team Houston Financial Abuse Specialist Team
MDT (No Name Provided) SB County MDT Center for Prevention of Abuse
Elder and Vulnerable Adult Abuse Task Force MDT (No Name Provided) Adult Protection Team
Cass County Adult Protection Team Multidisiplinary Team for Elder Abuse and Neglect Central Coast Scams Against Seniors Working Group
Texas Elder Abuse and Mistreatment Institute I Team Meeting (Interdisciplinary) I-Team of Barron County
MID County MDT Ashland County Interdisciplinary Team Oklahoma County Coalition Against Financial Exploitation of the Elderly
EAFC (No Name Provided) Catholic Charities, Diocese of Joliet Brown County Adult Protectin Team
CREA (Coordinated Response to Elder Abuse) Dodge County Adult Protective Services Interdisciplinary Team Cobb County Elder Abuse Task Force
Financial Abuse Specialist Team APS CROSS REGIONAL MDT Ingham County Elder Abuse Coordinated Community Response Team
Isanti County Adult Protection Team Adult Abuse Review Team (AART) Denver Forensic Collaborative
Clinton County Financial Exploitation MDT Denver Forensic Collaboarative for At-Risk Adults James City County Multidisciplinary Team
Kalamazoo Hoarding Multidisciplinary Team South County MDT Rock County I Team
Guilford County Elder Justice Committee S.A.V.E. Trempealeau County I-Team
Coalition Against Exploitation of the Elderly (CAFEE) Dependent Elder Abuse Review / Elder Death Review Team
Ontario County Enhanced Multidisciplinary Team Jefferson County Abuse/Neglect of Elder/Vulnerable Adults Interdisciplinary Team
Dss Protective Services for The Elderly
Sacramento CountyElder Death Review Team
Financial Abuse Specialist Team (FAST) of Ventura County
Alameda County Financial Abuse Specialist Teams
CAPE- Coalition for Abuse Prevention of the Elderly
134
APPENDIX F: CHAPTER 4 INSTRUMENT
ACL Survey 3b Draft
Purpose is to conduct a “process, practice, and impact” analysis of specifically-identified
elder abuse MDTs: of the MDTs that are identified as Elder Abuse Forensic Centers, we ask
specific, in-depth questions about processes, practices, and impacts/outcomes. Team members
are the target audience.
1. What is your educational background (check all that apply)?
• Less than high school
• High school diploma
• Bachelor’s degree
• Graduate degree

2. What agency do you represent?
• Text entry

3. What is your role in this MDT?
• Text entry

4. How long have you personally participated in [MDT name]?
• Less than 1 year
• 1-2 years
• 3-5 years
• 6+ years

5. How often do you attend meetings?
• Weekly
• 2-3 times per month
• Once per month
• Every other month
• Other (please specify)

6. How long had you worked on cases of elder mistreatment before participating in [MDT name]?
• Never
• Less than 1 year
• 1-2 years
• 3-5 years
• 6+ years

7. How did you first become aware of this MDT?
• My job/organization
• Email from [MDT Name]
• Internet search
• Word of mouth
• Other (please specify)

135
8. Why did you to join [MDT Name] as a team member? (check all that apply)
• Monetary compensation from the MDT
• Requirement set by my job/organization
• Seemed like a gratifying experience
• To help address difficult elder abuse cases in my professional work
• Professional networking opportunities
• Other (please specify)

9. What drives you to keep participating in [MDT Name] as a team member? (check all that apply)
• Monetary compensation from the MDT
• Requirement set by my job/organization
• It is a gratifying experience
• It has helped my job performance
• Professional networking opportunities
• Other (please specify)

10. If the leader of this MDT were to be replaced, this MDT would remain operational.
• Strongly agree
• Agree
• Neutral
• Disagree
• Strongly disagree

11. If the leader of this MDT were to be replaced, would you continue to participate as a team
member?
• Yes
• No

12. What does this MDT consider to be the top priority in case decision-making?
• Client safety/protection
• Supporting client self-determination
• Facilitating client wishes
• Cost effectiveness
• Legal action
• Client desires/wishes
• Client physical and mental health
• Other (please specify)

13. What does your job organization/agency consider to be the top priority in case decision-making?
• Client safety/protection
• Supporting client self-determination
• Facilitating client wishes
• Cost effectiveness
• Legal action
• Client desires/wishes
136
• Client physical and mental health
• Other (please specify)

14. What do you PERSONALLY believe should be the top priority in case decision-making?
• Cost effectiveness
• Client safety/protection
• Client autonomy
• Cost effectiveness
• Legal action
• Client desires/wishes
• Client physical and mental health
• Other (please specify)

15. Do case discussions include the client’s desires/wishes
• Yes
• No

16. If the client’s desire/wishes oppose the team’s goals/action plan for a case, is the case plan
adjusted?
• Always
• Often
• Sometimes
• Rarely
• Never

17. How often have you disagreed with a decision made on a case, whether or not you expressed that
disagreement to the team?
• Always
• Often
• Sometimes
• Rarely
• Never

18. [if disagree with decision] How often do you make this disagreement known to the team?
• Always
• Often
• Sometimes
• Rarely
• Never

19. How often do participating agencies offer each other assistance to work around case plan
barriers? (e.g., APS is unable to contact an elder’s physician, but an MDT-participating physician
offers help in contacting the elder’s physician)
• Always
• Often
137
• Sometimes
• Rarely
• Never

20. How often do you reach out to other participating agencies for assistance with a case?
• Always
• Often
• Sometimes
• Rarely
• Never

21. How has your relationship with participating agencies on the MDT impacted your work/practice?
• Very positively
• Positively
• Somewhat positively
• No effect
• Somewhat negatively
• Negatively
• Very negatively

22. BEFORE you joined this MDT, how often did you reach out to other agencies for assistance with
your work/practice?
• Always
• Often
• Sometimes
• Rarely
• Never

23. How has your OVERALL participation in [MDT Name] affected your work/practice?
• Very positively
• Positively
• Somewhat positively
• No effect
• Somewhat negatively
• Negatively
• Very negatively

24. Have you ever felt unable to properly voice your opinion or suggestion during an MDT meeting?
• Yes
• No

25. [If yes] Which best describes the reason for not being able to voice your opinion/suggestion?
(check all that apply)
• Other team members cut me off
• Other team members dominate the conversation
138
• I am not comfortable with public speaking
• The meeting ran out of time
• My opinion/suggestion would not have been received well by the team
• Other (please describe)

26. If I/my organization voices an opposing opinion on a case decision at a team meeting, the
decision is re-evaluated.
• Strongly agree
• Agree
• Neutral
• Disagree
• Strongly Disagree

27. In your opinion, please rate this MDTs level of success:
• Very successful
• Successful
• Somewhat successful
• Neutral
• Somewhat unsuccessful
• Unsuccessful
• Very unsuccessful

28. How do you PERSONALLY measure this MDTs success? (i.e., what are specific criteria you use
to be able to say “this MDT is successful” or “this MDT is unsuccessful”?)
• Text entry

29. The AGENCY I represent contributes to the overall success of [MDT Name].
• Strongly agree
• Agree
• Neutral
• Disagree
• Strongly disagree

30. I personally contribute to the overall success of [MDT Name].
• Strongly agree
• Agree
• Neutral
• Disagree
• Strongly disagree

31. Please describe how you and the agency you represent contribute to the overall success of [MDT
Name].
• Text entry

32. Were you involved in the creation of this MDT?
139
• Yes
• No

33. [If Yes] In your opinion, how challenging was it to establish [MDT Name].
• Extremely challenging
• Challenging
• Somewhat challenging
• Not challenging

34. [If Yes] What was your role in helping to establish this MDT?
• Text entry

35. [If Yes] What were the major barriers in establishing this MDT? (check all that apply)
• Acquiring sufficient funds
• Recruiting participating agencies
• Finding cases to review
• Establishing support from policy makers
• Other (please specify)

36. [If Yes] Are you aware of any resources that would guide someone trying to establish an MDT
like yours?
• Yes (please specify)
• No

37. If there is any relevant information about your MDT that was not captured in this survey, and you
would like to share, please describe it below.
• Text entry

Abstract (if available)

Abstract Elder abuse and mistreatment are pervasive public health problems that negatively affect the well-being of 1 in 10 older adults in the United States (Acierno et al., 2010

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Asset Metadata

Creator Galdamez, Gerson (author)

Core Title Developing a better understanding of elder abuse multidisciplinary teams: addressing gaps for research, policy, and practice

School Leonard Davis School of Gerontology

Degree Doctor of Philosophy

Degree Program Gerontology

Publication Date 10/23/2020

Defense Date 05/05/2020

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

Tag Abuse,Age,aging,Criminal Justice,elder,elder abuse,financial exploitation,forensic,forensic center,Gerontology,health,healthcare,Justice,mistreatment,multidisciplinary,neglect,OAI-PMH Harvest,old,organizations,policy,system,team

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Wilber, Kathleen (committee chair), Gassoumis, Zachary (committee member), Tucker-Seeley, Reginald (committee member)

Creator Email gersongaldamez42@gmail.com,ggaldame@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-382610

Unique identifier UC11666316

Identifier etd-GaldamezGe-9058.pdf (filename),usctheses-c89-382610 (legacy record id)

Legacy Identifier etd-GaldamezGe-9058.pdf

Dmrecord 382610

Document Type Dissertation

Rights Galdamez, Gerson

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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