Evaluation of AoA’s Elder Abuse Prevention 

Intervention Demonstrations

ASPE | July 2015

Research Brief

Enacted as part of the Patient Protection and Affordable Care Act in March of 2010, the Elder Justice Act 

represents the most comprehensive federal elder abuse prevention law to date, calling national attention to 

the millions of vulnerable older Americans who are victims of abuse, neglect, and exploitation. The Elder 

Abuse Prevention Interventions demonstration, authorized by the Elder Justice Act and funded by the 

Administration on Aging (AoA), U.S. Department of Health and Human Services (HHS) in FY 2013, provided 

funding to five state grantees to test interventions designed to prevent elder abuse, neglect, and exploitation. 

The HHS Office of the Assistant Secretary for Planning and Evaluation has contracted with NORC at the 

University of Chicago to design and conduct an evaluation of the interventions being tested through this 

demonstration. The purpose of the evaluation is to study the development and implementation of the state 

grantees’ elder abuse interventions and report findings on the characteristics of victims and perpetrators of 

elder abuse or those at-risk, the use of prevention services, and outcomes. 

The states participating in the demonstration and evaluation are: Alaska Division of Senior and Disabilities 

Services; New York State Office for the Aging; University of Southern California; University of Texas Health Science Center at Houston; and Texas 

Department of Family and Protective Services and WellMed Charitable Foundation. This Research Brief is one of five summarizing the tested 

interventions and findings to date.

Use of the Elder Abuse Suspicion Index © (EASI) Screening Tool and 

Adult Protective Services (APS) Specialists in a Clinical Setting 

Texas Department of Family and Protective Services, 

WellMed Charitable Foundation, and Benjamin Rose Institute on Aging 

OVERVIEW 

Texas APS is the lead agency in the intervention. Established in the 1970s, 

APS is the primary state agency that investigates abuse, neglect, and 

exploitation for the state of Texas. 

WellMed Charitable Foundation, the primary partner in the intervention, is 

an independent nonprofit and philanthropic partner to WellMed Medical 

Management Inc., a multi-medical specialty group. As a “capitated” full-risk 

Managed Service Organization, WellMed assumes full-risk for their 

patients’ healthcare costs. Every patient is cared for by a multi-disciplinary 

team that includes a physician, specialist, health coach, social worker, and 

disease management staff, among others. 

The project director at WellMed works with staff at APS to oversee the 

implementation of the intervention. The APS regional director supervises 

the two APS specialists. The APS specialists serve as the liaison between 

APS and WellMed, conduct educational trainings, and serve as a resource. 

Benjamin Rose Institute on Aging serves as the local evaluator. Robert 

Blancato from the Elder Justice Coalition is another collaborating partner 

who will help disseminate findings at a national level.

The TX/WellMed intervention addresses elder abuse, neglect, and

exploitation among cognitively alert, primary care patients and provides

support to caregivers of patients with dementia or Alzheimer’s disease. The 

intervention consists of four main components: 1) embed APS specialists

at WellMed to serve as an on-going resource; 2) train clinicians in primary

care clinics on screening and identification of abuse among cognitively

intact patients; 3) administer the EASI suspicion index in clinics and follow 

appropriate protocols to report cases of actual or suspected abuse to APS 

and/or WellMed complex care workers; and 4) refer caregivers of patients 

with dementia or Alzheimer’s disease to the Caregiver SOS Program. All 

four components of the intervention are being locally evaluated by a team 

of researchers led by Dr. Ejaz from the Benjamin Rose Institute on Aging. 

The Texas Department of Family and Protective Services, in partnership 

with the WellMed Charitable Foundation (TX/WellMed) and WellMed 

Medical Management Inc., is testing the feasibility of using the Elder Abuse 

Suspicion Index © (EASI) in a clinical setting to identify at-risk elders and 

prevent elder abuse. The screening protocols are being implemented in 73 

of WellMed primary care clinics in five areas of Texas: San Antonio, Austin, 

Corpus Christi, the Lower Rio Grande Valley, and El Paso. Clinicians in the 

five regions are being trained on elder abuse, neglect and exploitation, 

instruction on how to use the EASI tool, and the use of clinical protocols for 

referring flagged cases to APS and complex care workers. TX/WellMed is 

also embedding two Adult Protective Services (APS) Specialists within 

WellMed to help with the training, provide technical assistance, 

communication facilitation, and education that supports increased 

screening to prevent elder abuse. 

KEY FINDINGS TO DATE 1

Theoretical/Clinical Basis of Prevention Intervention 

The idea for administrating the EASI Suspicion Index in WellMed clinics 

was motivated by WellMed’s knowledge of the tool from a prior

collaboration with Lucy Barylak, MSW, in Montreal. The tool was

developed and tested in Canada in family medicine centers and in a

community organization but has not been tested with older patients in 

primary care clinics. Partners believed it was important to test the use of

the EASI to screen and identify abuse with this population.

Prevention Intervention 

Outcomes 

The intended outcomes include examining: 1) the impact of embedding 

APS workers in the WellMed system; 2) changes in knowledge of abuse 

and its reporting before and after the training and approximately a year

later; 3) the feasibility of using the EASI in primary care clinics and the 

fidelity with which the reporting protocols were followed; 4) number of 

cases referred to APS; and 5) changes in caregiver outcomes as a result 

of participating in caregiver programs. These outcomes are likely to 

improve the identification of abuse, reduce the risk for future abuse and 

increase collaborations among community partners.2

INFRASTRUCTURE 

Evaluation of AoA’s Elder Abuse Prevention Intervention Demonstrations | July 2015 | Page 1 
Texas Department of Family and Protective Services and WellMed Charitable Foundation: Use of the EASI Screening Tool and APS Specialists in a Clinical Setting

ELDER ABUSE IN TEXAS

Texas APS completed 81,681 investigations of suspected cases of abuse, 

neglect, and exploitation of elders 65 years of age and older and persons 

with disability in FY 2014. On average, the victim is a white female and the 

perpetrator is an adult female over 45 years (generally the adult daughter). 

The majority of elder abuse cases in Texas involve self-neglect.

INTERVENTION 

Target Population

The target population for the administration of the EASI screening tool is all 

patients at 73 clinics in the five regions participating in the intervention. 

WellMed primarily serves Medicare eligible patients ages 65 or older or 

those with disability and has a predominantly Hispanic clientele. 

Thus far, the EASI tool has been administered to more than 7,500 patients. 

On a weekly basis, WMMI receives about 100 completed tools from clinics 

that have been trained. In addition to referrals made to APS based on the 

EASI tool, the APS Specialists in WellMed have consulted on over 400 

client cases suspected of abuse during patient care coordination meetings. 

APS Specialists as a Resource: Two APS specialists (one of whom is 

bilingual) are embedded at WellMed and serve as a resource by providing 

educational training. APS specialists also provide consultation to clinical 

staff through individual inquiries or patient care coordination meetings 

where patients identified as high risk (for being hospitalized, discharged 

home or some other issue) are discussed among a team of WellMed staff. 

Clinical Training: For each of the five regions, APS specialists provide 

training to clinicians on elder abuse, neglect and exploitation, instruction on 

how to use the EASI tool, and the clinical protocols for reporting flagged 

cases to APS and WellMed’s complex care workers. 

EASI Tool Administration: The EASI has been incorporated into the 

electronic medical record. There is a two-step process to administer it. 

■ Step 1 (EASI Tool Administration): The six-item EASI tool is

administered to cognitively intact patients without the presence of

their caregiver at least once a year. Typically, the first five questions

are asked by the medical assistant who is already recording the

patients’ vital signs. These are:

1. Have you relied on people for any of the following: bathing,

dressing, shopping, banking, or meals?

2. Has anyone prevented you from getting food, clothes,

medication, glasses, hearing aids or medical care, or from being

with people you wanted to be with?

3. Have you been upset because someone talked to you in a way

that made you feel shamed or threatened?

4. Has anyone tried to force you to sign papers or to use your

money against your will?

5. Has anyone made you afraid, touched you in ways that you did

not want, or hurt you physically?

Once completed, the tool is handed off to the physician who then 

completes the last question: 

6. Elder abuse may be associated with findings such as: poor eye

contact, withdrawn nature, malnourishment, hygiene issues,

cuts, bruises, inappropriate clothing, or medication compliance

issues. Did you notice any of these today or in the last 12

months? If the patient responded “yes” to any of the first five

questions, the physician may ask clarifying questions about the

situation and probe further.

■ Step 2 (Risk Assessment and Referral): WellMed uses a “stoplight”

approach to identify the risk level for elder abuse and the appropriate

corresponding protocol to follow. Patients falling into the high-risk/red

category are reported to APS and referred to WellMed’s Complex

Care workers. Patients in the elevated risk/yellow category are

referred to Complex Care for follow-up. Patients in the low-risk/green

category do not receive intervention. All patients, regardless of rating,

are offered educational materials on elder abuse, neglect and

exploitation; and families receive information on caregiver stress.

Caregiver SOS: Caregivers of patients with dementia or Alzheimer’s 

disease are directed to Caregiver SOS (the umbrella program for all of 

WellMed’s caregiver services) and are specifically referred to the StressBusting Program for Family Caregivers,TM an evidence-based program 

focused on education, support, problem-solving, and stress management.

IMPLEMENTATION 

While adjustments have been made over the course of the intervention, the 

components of the intervention were largely implemented as intended.

One unanticipated finding was the number of referrals to APS that were 

generated through the patient care coordination meetings, which was not 

originally a feature of the intervention. The EASI tool may or may not have 

been completed on these patients.

Factors facilitating the implementation of the intervention include the 

uniqueness of WellMed as a medical practice (every patient is supported 

by a primary care team and has access to social services through Complex 

Care Workers), training of clinicians, and the complementary services that 

APS and WellMed provide. Whereas APS can assist in investigating cases 

of suspected abuse and provide short term services, WellMed addresses 

their medical and social service needs on a continual basis.

Barriers to the intervention include time constraints in administering the 

EASI tool and occasional clinician discomfort with APS.

LESSONS LEARNED 

The project is still in its implementation phase. Preliminary analysis of the 

data from over 500 clinicians who completed both the pre-and post-training 

surveys demonstrates that clinicians experienced significant improvements 

in their knowledge of abuse, Texas law, and reporting. The findings 

suggest that elder abuse training is likely to greatly benefit clinicians in 

primary care settings. Incorporating the EASI tool in the electronic medical 

record is an important means of ensuring that clinicians complete a screen 

to identify abuse and follow appropriate reporting protocols. Further, the 

presence of APS workers as a resource and during care coordination 

meetings is an innovation that is likely to improve the identification and 

prevention of abuse in a timely manner. In order to meet the needs of the 

most vulnerable population of older adults, collaborations between APS 

and health care systems and other community agencies are required to 

increase awareness of abuse and its prevention.

FOR MORE INFORMATION CONTACT

■ Principal Investigator: Texas Department of Family and Protective

Services - Rachel Duer, Rachel.Duer@dfps.state.tx.us 210-871-3036

■ WellMed: Carol Zernial, czernial@wellmed.net 210-877-7719

■ Local Evaluator: Farida Ejaz, fejaz@benrose.org 216-373-1660

Suggested Citation: Nguyen, K., Hafford, C. & Henning, S. June 2015. Use of the EASI 

Screening Tool and APS Specialists in a Clinical Setting. Elder Abuse Prevention Intervention 

Program. Washington, DC: Assistant Secretary for Planning and Evaluation, U.S. Department 

of Health and Human Services: NORC at the University of Chicago. 

1

 Findings to date are based on a two-day site visit to UT Health in December 2014 to learn about planning, infrastructure and implementation of the prevention intervention and progress to date. Program 

documents were reviewed and key informant interviews conducted with the research team, APS, and geriatrician. NORC accompanied staff on a home visit. NORC thanks UTHealth for hosting the visit. 2 Outcome data will be analyzed in mid-2015.

Evaluation of AoA’s Elder Abuse Prevention Intervention Demonstrations | July 2015 | Page 2