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.

Medication Self-Adherence Prevention Intervention for 

Community-Dwelling Elders Who Self-Neglect 

University of Texas Health Science Center

OVERVIEW 

The University of Texas Health Science Center (UTHealth) at Houston, in 

partnership with Adult Protective Services (APS), the Texas Department of 

Aging and Disability Services (DADS), and the Houston area justice 

system is pilot testing an intervention to increase medication adherence in 

older adults who have chronic health conditions and who neglect 

themselves. The tailored health promotion intervention implemented by 

UTHealth is aimed at increasing the active participation of elder selfneglecters in managing their chronic disease medications, reducing their 

level of social isolation, and implementing environmental supports to 

increase medication adherence.

KEY FINDINGS TO DATE 1

Theoretical/Clinical Basis of Prevention Intervention 

Medication non-adherence is prevalent among older adults with chronic 

diseases,2 particularly among self-neglecting elders, and is linked to 

increased morbidity and mortality. Interventions to date have not 

addressed this population. 

UTHealth is implementing a two-year community-based intervention that 

targets older adults who have a substantiated report of self-neglect. The 

intervention is modelled on an effective home-based treatment protocol 

using environmental cues and supports to improve medication adherence 

with a population of adults with severe mentally illness.3 Adapted to selfneglecting elders with multiple chronic conditions, the prevention 

intervention involves a comprehensive assessment of knowledge, capacity, 

and risk factors that guide weekly home visits by a registered nurse (RN) 

and research associate (RA). 

Prevention Intervention 

The intervention involves a one month education period using tailored 

approaches and environmental supports to reduce non-adherence 

behaviors, followed by five-months of reinforcement. After six months, the 

team provides educational reinforcement if there is a safety concern or a 

participant requests guidance or assistance. 

Outcomes 

The short and long-term outcomes of the intervention are to increase 

medication adherence and reduce adverse outcomes associated with elder 

self-neglect, including social isolation, dependence, health problems, and 

likelihood of re-referral to APS. 

INFRASTRUCTURE 

The prevention intervention is housed within the Texas Elder Abuse and 

Mistreatment (TEAM) Institute, located at the Quentin Mease Community 

Hospital. In 1997, UTHealth formed the TEAM Institute with the Texas 

Department of Family and Protective Services and its Adult Protective 

Services (APS) unit, the Harris County Hospital District, and the Baylor 

College of Medicine. The TEAM Institute is the first medical school, public 

hospital, and state APS collaboration in the United States. Key partners 

involved in implementing the prevention intervention are UTHealth and 

APS Region VI. APS is the referral source for the self-neglecting elders 

and provides access to administrative data. The Area Agency on Aging 

serves on the project advisory committee along with APS.

ELDER ABUSE 

The UTHealth prevention intervention takes place in APS Region VI, which 

has 13 counties. According to the 2014 Annual Data Book the population 

age 65 or older in this region is 647,612.4 The incidence of maltreatment 

per 1,000 adults is 10.2 (the statewide incidence is 11.4). Each year there 

are more than 15,000 reports to APS regarding elder abuse and neglect. In 

Fiscal Year 2014, there were 10,178 validated in-home investigations 

(54,731 statewide).5

 Elder self-neglect crosses economic and ethnic lines. 

Self-neglecting elders tend to experience high rates of poverty (although 

some are “well-off”), have limited education, live in substandard housing 

(sometimes without electricity or utilities), have untreated mental health 

issues (e.g., depression), may lack medical coverage, and have low levels 

of health literacy. Home environments can be unsafe or unsanitary. 

INTERVENTION 

Target Population

The target population are self-neglecting elders who meet the following 

inclusion criteria: 1) 65 years of age or older; 2) English or Spanish 

speaking; 3) community living (i.e., personal residence); 4) APS 

substantiated self-neglect (with no other substantiated allegations). 

Additional criteria are: 1) currently taking medications for a chronic disease; 

2) demonstrates capacity (i.e., able to provide informed consent); and 3)

within a reasonable driving distance. UTHealth enrolled 34 elders. 

Medication Adherence Prevention Intervention 

The prevention intervention includes multiple components: referral and 

intake; informed consent; a six-month medication adherence intervention; 

and a six-month follow-up phase. 

Evaluation of AoA’s Elder Abuse Prevention Intervention Demonstration | July 2015 | Page 1 
University of Texas Health Science Center: Medication Self-Adherence Prevention Intervention for Community-Dwelling Elders Who Self-Neglect

Referral and Intake: The three step enrollment process involves both APS 

and the UTHealth team. 

■ Step 1: The APS caseworker conducts a home visit with a

substantiated self-neglecting elder and asks if s/he is interested in the

medication adherence intervention. (They carry a laminated card with

the inclusion criteria and instructions). If so, the caseworker obtains

the elder’s signature on a DFPS release form (in English and

Spanish) and faxes it to UTHealth in order to contact the elder.

■ Step 2: The research staff calls the elder to verify eligibility. If the

inclusion criteria are met, a home visit is scheduled within one week.

■ Step 3: Research staff lead the participant through the informed

consent process. Elders must demonstrate their understanding of the

purpose of the study, its risks and benefits, as well as the nature of

their participation and the research team’s involvement. This can take

up to 1 1⁄2 hours. During the consent process, research staff read the

entire consent form aloud while the elder reads a paper copy. Each

elder must repeat key elements of the study and intervention back to

the research staff before signing the consent and being enrolled.

Intervention: The 6 month intervention focuses on social support and 

medication management through monthly, one-hour home visits, premised 

on communication and engagement. 

■ In Months 1 and 2, activities focus on the baseline assessment, the

medication safety assessment, and education. Research staff—a

registered nurse (RN) and research associate (RA)—make a joint

home visit to conduct the baseline evaluation, including a medical

history and comprehensive assessment on knowledge and behaviors

associated with medication adherence, cognitive capacity,

functioning, motor skills, social support, depression, and

environmental stressors. They take an inventory of all medications,

documenting quantity, dosage, refills, and adherence.

■ Following the visit, the geriatrician conducts a medication safety

assessment, evaluating each medication on 10 criteria: drug

indications; effectiveness for the condition; correct dosage; correct

directions; practical directions; clinically-significant drug-drug

interactions and drug-disease/conditions interactions; unnecessary

duplication with other drug(s); acceptable duration of therapy; and

whether the drug is the least expensive alternative compared to

others of equal utility. Based on the MAI, Beers, and Micromedex

findings, the medication is either approved or disapproved. The

geriatrician completes the medication approval within a week.

Education: Next, the Research Team tailors the education component to 

each elder’s knowledge and personal efficacy skills. Priority areas for 

intervention and education are: medication adherence; knowledge 

deficiencies (label reading, dosage, purpose, frequency, and effects); selfefficacy (scenarios where the elder is not confident); skills (filling a glass 

with water, opening pill container, counting, sipping and swallowing); and 

possible placement for environmental cues (central location of medications 

in the home, pillbox, alarm clock, and post-it note reminders).

■ Education and reinforcement involves home visits over a three-week

period. The RN and RA work with each elder to review medicines,

symptoms and side effects, and their personal goals. They set up a

daily schedule for each elder, provide medication alert reminders, and

teach elders on making the environmental cues part of their daily

routines. A “pill count” of medications taken for each prescription is

done twice in the first month. Research staff also make weekly phone

contact with the elders. Urgent medical needs identified during home

visits that require immediate attention are communicated to the

elders’ primary care physician. Research staff hold team debriefings

to alleviate stress and secondary traumatic stress.

■ During months 2-6, the RN and RA make joint home visits to provide

further education and troubleshoot medication management

concerns. The RN takes vitals and checks on adherence to the

prescribed regimen. Weekly calls continue. The RA conducts the

monthly medication review.

■ During Months 3-6, the RN obtains medical and social history data.

Participants receive $25 compensation during month 6.

■ Actual implementation of these steps can vary for participants due to

their situations.

Follow-up: In Months 6-12, the RN and RA schedule home visits, monitor 

medication adherence through usage data, and provide educational 

reinforcement if there is a concern. In Months 9-12, the RN again obtains 

medical and social history data and reassesses the baseline to determine 

any regression of medication adherence. All data are entered into the study 

database.6 Participants receive $25 compensation in month 12.

IMPLEMENTATION 

The medication adherence prevention intervention has been fully 

implemented as intended with 34 participants enrolled as of December 

2014, with no significant changes to the study protocol. 

No unintended 

consequences have been 

observed. No adverse 

events have occurred. 

A key facilitator to the sound 

implementation of the 

prevention intervention was 

use of Intervention Mapping to target critical components to achieve the 

desired behavioral outcomes. Engagement of the research staff in 

developing the study protocols and manualizing the intervention, along with 

consistency in staffing, facilitated consistent implementation. 

As is common with similar interventions, and with this vulnerable 

population, some elders were initially hesitant to participate which affected 

initial recruitment and enrollment. 

UTHealth brings a strong record of research and leadership to the field of 

elder self-neglect, as well as resources within the University to draw upon. 

Its long-standing partnership with APS Region VI is a key facilitator to both 

the development and implementation of the prevention intervention. 

Research staff stated that elders are grateful 

for the services provided. Elders said 

participating in the intervention “made a 

difference,” helping them to keep to a “normal 

schedule” and “improving sleep patterns.” 

One simply noted, “It saved my life.”

LESSONS LEARNED 

The population has medications that are either contraindicated for older 

adults or are dangerous in combination with other medications. Thus, there 

needs to be a strong screening process of the medications before 

implementing an adherence protocol in order to ensure participant safety.

Developing a helping relationship with vulnerable elders and becoming a 

needed, dependable presence in their lives is a “huge responsibility.” 

Implementation takes strong rapport building skills to initiate contact with 

elders and sustain their engagement over time. It requires compassion, 

patience, professionalism, and constant mindfulness of ethical practice and 

research. Balancing elder autonomy and safety is an ever-present concern.

An interesting realization is that the weekly contact and home visits may be 

a contributing factor to participants’ improved adherence to the medication 

regimen and their physical and mental well-being. Whether and how social 

visits mediate outcomes will be an important analytic question to explore.

FOR MORE INFORMATION CONTACT

The University of Texas Health Science Center at Houston

■ Principal Investigator: Carmel B. Dyer, MD

■ Co-PI: Jason Burnett, PhD Jason.Burnett@uth.tmc.edu 713.873.4685

Suggested Citation: Hafford, C. Nguyen, K. & Henning, S. June 2015. Medication SelfAdherence Prevention Intervention for Community-Dwelling Elders who Self Neglect. 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 Bodenheimer, T, Lorig. K., Holman; H. et al. (2002). Patient Self-management of Chronic Disease in Primary Care. JAMA; 288(19):2469-2475; Dunbar-Jacob, J. & Mortimer-Stephens, M-K. (2001). 

Treatment adherence in chronic disease. Journal of Clinical Epidemiology 54: S57–S60. 3 Velligan, D.I. et al. (2008). The Use of Individually Tailored Environmental Supports to Improve Medication Adherence and Outcomes in Schizophrenia. Schizophrenia Bulletin May; 34(3): 483–493. 4 2014 Data Book, page 12. Retrieved from http://www.dfps.state.tx.us/About_DFPS/Data_Books_and_Annual_Reports/2014/default.asp 5 2014 Data Book, page 13. 6 All data collected will be analyzed in mid-2015 when the intervention phase ends. 

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