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April 6, 2022
The Health of Aging Populations Delivery System Reform Social Determinants of Health
Esther M. Friedman
May 18, 2022
Feb 1, 2022
Sep 27, 2021
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By Kate McEvoy
Elder abuse has long been a multifaceted challenge that is likely very much underreported. Despite the attention and advocacy that has been brought to bear on this issue at the federal level, as well as groundbreaking policy commitments and resources associated with the Elder Justice Act, the frequency of elder abuse has continued to increase and has likely been exacerbated during the pandemic as families have had to shelter in place in close confines.
For these reasons, we are glad to share a profile of the Harry and Jeanette Weinberg Center for Elder Justice at the Hebrew Home at Riverdale, in the Bronx, New York. This emerging model challenges our traditional thinking about bricks-and-mortar shelters through an innovative approach that embeds cross-disciplinary elder abuse supports within the existing structure of a large integrated hospital system. As the authors note, this approach has the potential to augment a system’s ability to effectively respond to the emerging needs of victims of abuse, develop and localize its geriatric care capacity, help people return to their home settings, and save money on acute and long-term care. It is exciting to see both that the model has clear near-term benefits and that the proponents are partnering with the RAND Corporation to carefully examine the longitudinal impact of the intervention.
Elder abuse is pervasive and correlated with deleterious health outcomes, resulting in burdensome costs to health care and social service systems. Embedding an elder abuse shelter program within a larger health care system serving older adults is a promising practice with the potential to maximize use of available resources and improve outcomes on a significant scale. The elder shelter model, pioneered by the Harry and Jeanette Weinberg Center for Elder Justice at the Hebrew Home at Riverdale and now replicated in more than a dozen communities nationwide, addresses a critical gap in services for older adults experiencing abuse. These individuals often remain in unsafe situations because they have nowhere to go to simultaneously address both their medical needs and the legal, financial, and social-emotional consequences of the abuse they have experienced. The shelter model program can be contained in a single long-term care facility like the Weinberg Center or exist without walls in a particular geographic area, with multiple facilities, agencies, or organizations coordinating services.
An initial evaluation of the Weinberg Center by the RAND Corporation found preliminary evidence that participation in a shelter model program may improve health outcomes within continuum-of-care settings for older adults who have experienced abuse in their homes. Beyond its direct impact on program participants, embedding elder abuse shelter programs within the health care system has several systemic policy implications, potentially allowing health care systems to use existing resources more effectively while promoting successful aging in place and improving quality of care for all patients, residents, and clients.
Community-based elder abuse is a public health crisis of vast proportions. The U.S. Department of Justice’s Elder Justice Roadmap indicates that one out of every 10 people over 60 who lives at home is the victim of abuse, neglect, or exploitation.1 Elder abuse has significant implications for the physical and financial health and well-being of older adults.
Elder abuse also comes with huge financial costs.2 The impact of abuse and the trauma it causes goes beyond individuals, affecting families as well as the government and community institutions that support the high-cost medical interventions and social service programs that victims often require.
Despite the dramatic impact elder abuse has on families and society, health care systems have done little to systematically identify and address elder abuse. According to the 2011 report Under the Radar: New York State Elder Abuse Prevalence Study, for every case of elder abuse reported to law enforcement or social service agencies, 23 more go unreported.3 Even when cases are known to service providers, older adults often require intensive, well-coordinated services to support them in addressing the all-encompassing impact of abuse on their lives.
A critical roadblock to effective advancement in this arena is the lack of safe and appropriate emergency housing options for people who experience elder abuse. Typical emergency housing options such as homeless or domestic violence shelters are often ill-suited to older adults. People experiencing elder abuse may have medical needs or cognitive impairments that cannot be accommodated in shelters, and shelters’ culture and range of services generally cater to a far younger demographic. As a result, these individuals are often forced to return home to unsafe environments. Where housing options for older adults experiencing abuse do exist, they are typically uncoordinated across systems, leaving these adults at risk of receiving insufficient support, repeat abuse, and adverse physical, emotional, and financial outcomes.
Overview. The Harry and Jeanette Weinberg Center for Elder Justice at the Hebrew Home at Riverdale, the nation’s first elder abuse shelter located within a continuum-of-care medical community, opened its doors in 2005. As so many short-term housing options are inaccessible to medically fragile older adults, the Weinberg model was conceived as combining excellent medical and clinical care with cutting-edge, trauma-informed elder abuse services. The shelter is virtual, in the sense that clients are placed throughout the continuum-of-care facility based on their individual medical needs. Clients who need rehabilitation can receive those services; clients who have cognitive impairment are on floors with specially trained professionals, uniquely designed physical space, and appropriate therapeutic activities; and clients with nursing needs are grouped with other residents requiring a similar level of care. At the same time, the Weinberg Center’s team of lawyers and social workers work with the client to craft and execute an individualized, strategic plan to address the abuse they have experienced and allow them to return safely to either their original home or wherever their next home may be. In this model, the older adult’s medical needs as well as the impact of the abuse on their health and functional ability are addressed contemporaneously with their legal and social service needs.
From its inception, fostering replication of this model has been a critical piece of the Weinberg Center’s mission. To that end, the Weinberg Center established the SPRiNG (Shelter Partners: Regional, National, Global) Alliance, a professional shelter network, to lend structure to its replication program.4 Currently, 14 shelter replications are in operation throughout North America, and others are in various stages of development, with 20 different communities represented within the SPRiNG Alliance.
Figure 1. SPRiNG Alliance Member Models
Each SPRiNG Alliance member program embodies the core values and ideas of the model while simultaneously creating a unique program based on the needs, resources, and stakeholders in its particular community (see figure 1). Some of the programs, like the Weinberg Center, are contained within a single long-term care facility (Model 1). Some, like the Pikes Peak Elder Justice Center in Colorado Springs, Colorado, operate on a collaborative model (Model 2). In this model, multiple facilities within a geographic area share the responsibility of sheltering elder abuse victims with a community-based organization, such as an aging agency, a legal services organization, or adult protective services, coordinating shelter admission and services. This configuration is particularly conducive to the realities of rural areas. Still others, such as the Statewide Emergency Elder Abuse Shelter in Utah, have created unique hybrid models that suit their community’s needs (Model 3).
Initial Evaluation of the Weinberg Center. To shed light on the potential benefits of its innovative model, the RAND Corporation undertook an initial evaluation of the Weinberg Center.5 The evaluation drew on an analysis of data collected by the Weinberg Center on clients upon entry and discharge, interviews with Weinberg Center staff, and a literature review. This combination of data was used for a preliminary exploration of the impact of residence in the Weinberg Center on client outcomes and the program’s potential cost savings for stakeholders under different scenarios.
To identify changes in medical indicators of interest (i.e., depression, cognition, pain, and mobility) over the course of a stay at the Weinberg Center, the research team examined the medical trajectories of clients over the course of their four Medicare medical assessments undertaken at the Weinberg Center.
The evaluation found that the Weinberg Center provided a suite of coordinated services to its clients during their stays, many of which would not have been provided in a traditional, non-medical-facility shelter setting. Examining the clients’ trajectories in the center, the research team found that numerous clients presented with physical and mental health issues. These included limited mobility (99%), pain (25%), cognitive impairment (48%), and depression (88%). Over the course of their Medicare medical assessments (spanning nine months after intake), the client group largely recorded stable health and functioning during their time in the center. Further, when clients’ health status did not remain stable, improvements were more common than deteriorations.
These observations stand in contrast to what we know about typical trajectories for older adults, which usually show a decline in these outcomes.
These results are preliminary, as the initial evaluation was limited in scope and confined to descriptive analyses of outcomes among the Weinberg Center client population. The research team is developing a rigorous and comprehensive evaluation framework and data collection strategy that will enable both a more precise determination of the benefits that accrued to Weinberg Center clients and attribution of these benefits to the center’s intervention.
Implications for Resource Optimization. Housing an elder abuse shelter within a continuum-of-care health care system allows the shelter program to leverage the extensive preexisting resources of that system to create a service providing a high level of care at a low variable cost. Health care facilities already operate with many features critical to the success of an elder abuse shelter. They are open seven days a week and nearly always have a bed available, they maintain a skilled nursing and therapeutic staff that has undergone mandated training, and they can provide services for both men and women. Whereas creating a free-standing elder abuse shelter would involve significant capital expenses, the Weinberg model involves low start-up costs, and resources can be focused almost entirely on direct service provision.
Implications for Aging in Place. Bringing clients into an elder abuse shelter program housed within a residential medical facility may, over the long term, result in enabling more vulnerable older adults to remain safely in their own homes. Though this conclusion may seem counterintuitive, consider the alternatives for older and medically fragile adults experiencing abuse in their homes. Given the prevalence of this kind of community-based elder abuse, most long-term care communities are already sheltering people experiencing elder abuse, who come in for short-term rehabilitation or respite stays, though the facilities may not be aware of the abuse or may be addressing emergent elder abuse issues on an ad hoc basis.6
Recent data collected by the Hebrew Home back up this commonsense conclusion. In addition to providing skilled nursing and assisted living levels of care, the Hebrew Home operates a sub-acute residential rehabilitation center on its main campus. Using the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS), an evidence-based validated screening tool developed by the Weinberg Center that focuses on circumstances and events within the past year, along with current and future risks, the Hebrew Home staff screened 536 rehab patients from May 2017 to May 2018. Nearly 12% (63 patients) had positive indicators of abuse, roughly mirroring the rate of elder abuse in the community at large—typically cited as affecting 10% of older adults.7,8
When no safe discharge option is available because abuse is ongoing or suspected, the path of least resistance is for the older adult to become a long-term resident of the care community. A shelter program embedded in this setting can potentially alter this cycle, allowing more older adults to return safely to their homes. Shelter model programs involve the development of a holistic service plan directly addressing the circumstances that led to the abuse. Such plans also include referrals and strategies aimed at ameliorating the loneliness so often experienced by people aging in place without sufficient communal supports, which makes them more vulnerable to repeated cycles of abuse and exploitation, with increasing costs and adverse health consequences.9
Creating an elder abuse shelter within a residential medical facility does not bring in a population who otherwise would not be patients there. Rather, it acknowledges the realities underlying the health symptoms these older adults are experiencing and addresses those circumstances at their root, with the goal of truly enabling clients to age in place safely in the community.
This programmatic structure may also create additional housing options for older adults who have experienced abuse. One such example is Hudson House, an independent, low-income senior building operated by RiverSpring Living, the Hebrew Home’s parent company, under HUD Section 202. RiverSpring Living successfully lobbied for a waiver allowing preferential admission for victims of elder abuse who had been clients of the Weinberg Center, provided those clients met age and income requirements. Integrating an elder abuse shelter program into a continuum-of-care community may provide opportunities for vertical integration of longterm housing options specifically catering to people who experience elder abuse.
Implications for Quality of Care. With the creation of a shelter program, the entire facility gains an in-house team of elder abuse experts, who can create protocols, train staff, and consult on cases, ensuring that elder abuse issues are addressed systematically and with the highest quality care throughout the institution. Opportunities to stop abuse, ideally early on, and to support healing are created for all the residents and clients in the medical facility, not just the clients directly admitted to the shelter program.
More generally and over time, trauma-informed care provided to shelter clients can influence a facility’s culture, fostering environments where residents’ experiences and desires are more likely to be seen, heard, and honored. Additionally, partnerships that the shelter program forges with community domestic violence, aging, law enforcement, and social service agencies specializing in elder abuse will make the care community part of a rich resource network of partners and collaborators that can help ensure safe discharges for short-term residents facing elder abuse in the community. The realization that every long-term care community already is serving elder abuse victims is a powerful illustration of how essential an elder abuse shelter is to addressing social determinants of health effectively and providing optimal care for every resident, patient, and client.
With the aging of the U.S. population,10 the incidence of elder abuse is likely to continue to increase concomitantly. The potential benefits of the Weinberg Center shelter model and the associated policy implications underscore the need to generate robust evidence that could support the model’s further development and replication. An initial evaluation of the Weinberg model suggests its potential to improve a range of physical and mental health outcomes for the client group. Although we do not discuss costs in detail here, the evaluation also noted potential cost savings for a variety of stakeholders. To more clearly quantify and confidently attribute benefits and savings to the intervention for key payers, for stakeholders, and for older adults experiencing abuse and their families, additional data collection and research is needed, chiefly in two areas. First, a greater systematic examination of what would have happened in the absence of the Weinberg Center intervention is needed, ideally incorporating an appropriate comparison group in the research design. Second, since many of the presumed benefits may take place over a longer period, follow-up data on the model’s clients as well as the comparison group are of great importance.
To address these issues, the National Institute of Justice has provided the RAND Corporation with support to undertake an evaluability assessment of the Weinberg Center and to develop a robust evaluation plan. The work is underway and is expected to conclude in 2022. A more complete picture of the costs and benefits of the shelter model will be critical for determining whether and how to scale this model across the United States to support older adults experiencing abuse so they can live happy, healthy lives in a setting they desire without fear of mistreatment or abuse.
1 U.S. Department of Justice, U.S. Department of Health and Human Services. The Elder Justice Roadmap. https:// www.justice.gov/file/852856/download. Published 2014. 2 True Link Financial. The True Link Report on Elder Financial Abuse 2015. https://www.truelinkfinancial.com/white_ papers/elder-financial-abuse-report/. Published January 2015. 3 Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center, New York City Department for the Aging. Under the Radar: New York State Elder Abuse Prevalence Study. https://ocfs.ny.gov/reports/aps/Under-the-Radar-2011May12. pdf. Published May 2011. 4 Trone J. Shelter: The Missing Link in a Coordinated Community Response to Elder Abuse. Harry and Jeanette Weinberg Center for Elder Justice. https://theweinbergcenter.org/wp-content/uploads/2019/04/Shelter.pdf. Published January 2019. 5 Smucker S, Friedman EM, Cahill M, Taylor J, Daly J, Shih RA. An Initial Evaluation of the Weinberg Center for Elder Justice’s Shelter Model for Elder Abuse and Mistreatment. RAND Corporation. https://www.rand.org/pubs/research_reports/RRA931-1.html. Published 2021. 5 Teresi JA, Ocepek-Welikson K, Ramirez M, Solomon J, Reingold D. Methodological approaches to the analyses of elder abuse screening measures: Application of latent variable measurement modeling to the WC-RAPS. J Elder Abuse Negl. 2019;31(1):1-24. doi:10.1080/08946566.2018.1523766 6 Ramirez M, Solomon J, Riquelme M, Santoro B, Reingold D, Teresi JA. Development and Spanish translation of the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS). J Elder Abuse Negl. 2019;31(1):38-55. doi:10.1080/08 946566.2018.1531099 7 Teresi JA, Ocepek-Welikson K, Ramirez M, Solomon J, Reingold D. Methodological approaches to the analyses of elder abuse screening measures: Application of latent variable measurement modeling to the WC-RAPS. J Elder Abuse Negl. 2019;31(1):1-24. doi:10.1080/08946566.2018.1523766 8 National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press; 2020. doi:10.17226/25663 9 Administration for Community Living. 2020 Profile of Older Americans. U.S. Department of Health and Human Services. https://acl.gov/sites/default/files/Profile%20of%20OA/2020ProfileOlderAmericans_RevisedFinal.pdf. Published May 2021.
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