Voluntary Consensus Guidelines for State Adult Protective Services Systems

May 2020

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ACL’s Vision

The Administration for Community Living (ACL) envisions a comprehensive, multidisciplinary system that effectively supports older adults and adults with disabilities so they can exercise their right to live where they choose, with the people they choose, and fully participate in their communities without threat of abuse, neglect, self-neglect, or financial exploitation. 

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ACL brings together the efforts and achievements of the Administration on Aging, the Office of Intellectual and Developmental Disability Programs, and the Department of Health and Human Services Office on Disability to serve as the federal agency responsible for increasing access to community supports, while focusing attention and resources on the unique needs of older Americans and adults with disabilities across the lifespan. 

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Building Consistency Among APS Programs

No federal formula grant funding for APS (like there is for the child welfare system)

States and local agencies have developed a wide variety of APS practices, resulting in significant variations

For example, APS systems differ in:

populations served

settings in which services are available

types of services provided

relationships with other service providers and the justice system

timeliness of responses

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APS programs are not subject to federal rules and regulations. As a result, each state has designed its own unique system. In addition, there is no single funding stream for APS, forcing states to look to multiple sources for funding and often leaving states with inadequate resources for their APS programs. 

Yet data from state APS agencies show an increasing trend in reports of maltreatment and increasing caseloads for APS workers (AARP Public Policy Institute, 2011; Teaster et al., 2006). These challenges can present significant obstacles to responding in an effective and timely way to reports of adult maltreatment. 

To support APS programs, it is more important than ever to demonstrate the effectiveness of APS programs and practices in improving client outcomes and provide states with tools to support effective and timely responses to adult maltreatment. 

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Why Develop APS Guidelines?

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The Guidelines were first published in 2016; the updated Guidelines were published in May, 2020

The Guidelines present one of the building blocks for developing a consistent and effective national APS system

In addition, the Guidelines fit into ACL’s vision of an abuse-free life for older adults and adults with disabilities.

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Building Blocks to a National APS System

ACL Office of Elder Justice and Adult Protective Services 

(OEJAPS)

APS Technical Resource Center 

(APS TARC)

National Adult Maltreatment Reporting System

(NAMRS)

Voluntary Consensus Guidelines for State APS systems

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ACL has taken several important steps to build a national “home” for APS starting in 2014 with the establishment of the Office of Elder Justice and APS. 

In 2015, the APS Technical Assistance Resource Center was created and soon after the National Adult Maltreatment Reporting System was started. 

In 2016, the National Voluntary Consensus Guidelines for State APS Systems were published.

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ACL Leadership in Federal Elder Justice Efforts

Today

Older Americans Act Title VII

National Center on Elder Abuse

Elder Justice Innovation Grants

Office of Elder Justice & APS

NAMRS

State APS Grants

APS TARC

APS Guidelines

Tomorrow

National Data on APS

Recommended Program Standards

Recommended Practice Models

TA for APS programs

Seamless Partnership with Aging & Disability Services

Evidence-based Interventions

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The investment that ACL is making today is intended to yield the “APS of tomorrow” including national data on APS, and national recommended standards.

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Purpose of the APS Guidelines

Provide a core set of principles and common expectations to encourage consistency among APS programs

Help ensure that adults are afforded similar protections and service delivery regardless of where they live in the U.S.

Support interdisciplinary and interagency coordination

Enhance effective, efficient, and culturally competent delivery

The Guidelines do not constitute a standard nor a regulation and will not create any new legal obligations, nor impose any mandates or requirements. They will not create nor confer any rights for, or on, any person. ACL will update the Guidelines at regular intervals.

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The Guidelines present a critical building block for building an effective response to adult maltreatment by helping to provide states with tools to support the implementation of effective and evidence-based strategies and practices for APS programs 

The Guidelines are:

Aspirational in nature

States and local agencies have developed a wide variety of APS practices, resulting in significant variations across the country

States identified them as something that would be helpful to them

A step that could be taken without Congressional appropriations

An important building block to the foundation of the APS of tomorrow

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ACL’s Approach for the Guidelines

ACL served as facilitator for the development of the 2016 Guidelines and for the updates of the Guidelines, including facilitating an extensive and wide-reaching stakeholder engagement and outreach process.

ACL applied the Office of Management and Budget (2016) and National Institute of Standards and Technology (2001) process for creating field-developed, consensus-driven guidelines. 

To eliminate unnecessary duplication and complexity in the development and promulgation of the Guidelines, ACL’s process remains consistent with the guidance of the National Institutes of Standards and Technology 15 CFR Part 287 (2020).

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ACL served as the facilitator for the development and updating of the Guidelines in conformity with federal standards for creating field-developed, consensus-driven guidelines.

The development of both the Guidelines and its updates consisted of multiple steps, including a review of research available on what works in APS agencies and in other analogous systems throughout the United States, and an extensive and wide-reaching stakeholder engagement and outreach process. 

The goal of the stakeholder engagement and outreach process was to hear from all stakeholders about their experiences with APS, ensure all stakeholders understood why and how ACL was leading the development of Guidelines for APS, and provide interested parties an opportunity to give input into the process and content of the Guidelines. 

Throughout the process, ACL’s stakeholder engagement and outreach endeavored to 

respect people’s history and experience with APS and their other life experiences; 

empower the public and stakeholders to contribute to the development of national APS guidelines in a meaningful way; 

understand the public’s vision for APS and for ACL’s role in APS; 

build consensus on proposed guidelines by including representatives from materially affected and interested parties, to the extent possible; and 

incorporate a civil rights/personal rights perspective in developing the system guidelines. 

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What Do the Guidelines Cover?

Program Administration

1A.	Ethical Foundation of APS Practice 

1B.	Protecting Program Integrity

1C.	Definitions of Maltreatment

1D.	Population Served 

1E.	Mandatory Reporters

1F.	Coordination With Other Entities

1G.	Program Authority, Cooperation, Confidentiality, and Immunity 

1H.	Staffing Resources

1I.	Access to Expert Resources

1J.	Case Review–Supervisory Process 

1K.	Worker Safety and Well-being

1L.	Responding During Community Emergencies 

1M.	Community Outreach and Engagement

1N.	Participating in Research

Time Frames

2A.	Responding to the Report/Initiating the Investigation 

2B.	Completing the Investigation 

2C.	Closing the Case

Receiving Reports of Maltreatment 

3A.	Intake

3B.	Screening, Triaging, and Assignment of Screened-in Reports

Conducting the Investigation

4A.	Determining If Maltreatment Has Occurred 

4B.	Conducting a Psychosocial Assessment 

4C.	Investigations in Residential Care Facilities 

4D.	Completion of Investigation and Finding

Service Planning and Service Implementation  

5A.	Voluntary Service Implementation   

5B.	Involuntary Service Implementation   

5C.	Closing the Case

Training

6A.	Case Worker and Supervisor Minimum Educational Requirements 

6B.	Case Worker Initial and Ongoing Training

6C.	Supervisor Initial and Ongoing Training

APS Program Performance

7A. 	Managing Program Data

7B. 	Evaluating Program Performance

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The 2020 and 2016 Guidelines have an identical overall structure, with the content organized by seven broad domains (or topics) and a number of specific elements (or subtopics) within each domain. 

For each element, the Guidelines contain a background section followed by the actual guidance statements. The background and guidance are informed by the research identified through the literature search. 

ACL drew intentionally from published research to help the Guidelines reflect the most recent evidence and best practices. 

ACL did not draw from current state laws or regulation to avoid limiting the Guidelines to practices currently in use. 

References to the child welfare system or child protective services are also included in the Guidelines to illustrate federal guidance for other analogous social services systems. These references are not intended to serve as guidance to the APS system, but rather, they serve as justification for providing federal-level guidance for APS programs, and they provide stakeholders with direct access to examples from child welfare system or child protective services for topics similar to those in APS (e.g., response times). 

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Seven Domains of APS Practice

Program Administration

Time Frames

Receiving Reports of Maltreatment

Conducting the Investigation

Service Planning and Service Implementation

Worker and Supervisor Training

Program Performance & Quality Assurance

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The seven domains that comprise the Guidelines cover the key elements of APS practice.  We will address each domain below, what topics it covers and some key recommendations.

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Domain 1: Program Administration

Broadest domain, comprising 14 elements (topics)

Encompasses elements related to the running of an APS program, but does not include practice-related items which are handled in other domains

Key recommendations include encouraging APS to: 

establish and adopt, and annually review, a code of ethics

have adequate staffing to handle caseloads 

share case information with law enforcement 

participate in multidisciplinary teams

provide resources to ensure worker safety

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Domain 1: Program Administration Elements

1A. Ethical Foundation of APS Practice 

1B. Protecting Program Integrity

1C. Definitions of Maltreatment

1D. Population Served 

1E. Mandatory Reporters

1F. Coordination With Other Entities

1G. Program Authority, Cooperation, Confidentiality, and Immunity

1H. Staffing Resources

1I. Access to Expert Resources

1J. Case Review–Supervisory Process 

1K. Worker Safety and Well-being

1L. Responding During Community Emergencies 

1M. Community Outreach and Engagement

1N. Participating in Research

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Here is a list of all 14 of the elements that comprise the first domain, Program Administration.  

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Domains that Guide Practice: 2─5

APS is charged with receiving and responding in a timely manner to reports of maltreatment and working closely with clients and a wide variety of allied professionals to provide services that maximize clients’ safety and independence. The following domains address these elements of APS practice:

Domain 2. Time Frames

Domain 3. Receiving Reports of Maltreatment

Domain 4. Conducting the Investigation

Domain 5. Service Planning and Service Implementation

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These four domains cover APS practice from intake through case closure. Each domain has several element, which are listed on the next slides. 

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Domain 2. Time Frames

Encompasses elements related to the timing (though not the content) of:

Case initiation

Investigation closure 

Case closure

Key recommendations include:

Visits to alleged victims should be face-to-face.

Two levels of response are outlined: within 24 hours for emergency cases and within 5 days for less imminent cases.

No recommendations are offered as to time frames for completing the investigation or closing the case.

However, guidance is provided as to what should be considered for creating policy about time frames.

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According to the APS Survey, most APS systems prioritize reports into either emergency or nonemergency situations and have time frames for responding in either a few hours or a few days, as deemed appropriate (National Adult Protective Services Association [NAPSA] & National Association of States United for Aging and Disabilities [NASAUD], 2012). 

In more than 35% of the states, staff must initiate an investigation within the first 24 hours, but in 45% of the states, it must be initiated in a shorter time period than the first 24 hours. 

Recent data (2017) from the National Adult Maltreatment Reporting System (NAMRS) shows that, on average, states took 4.5 days from receipt of a report of alleged maltreatment to the time APS made contact with the client (Aurelien et al., 2018a). 

The time frame in which APS systems must complete the investigation varies greatly. 

The APS Survey reveals that 31% of programs must complete the investigation within 30 days, and 42% states allow the investigation to be completed in more than 30 days. Eight states have no time frame for completing the investigation (NAPSA & NASUAD, 2012). 

Based on the 2017 NAMRS data, states took on average of 47.7 days to complete investigations. Out of 26 states that provided additional data, 17.8% reported investigations were closed within 15–30 days of receipt of report, 31.5% reported investigations were closed within 31–60 days of receipt of report, and 13.6% reported investigations were closed within 61–90 days of receipt of report (Aurelien et al., 2018a). 

The length of time that cases remain open for APS to provide services varies. According to the APS Survey, as of 2012, 40% of programs reported no specific time frame for closing cases, and eight required closure within 90 days (NAPSA & NASUAD, 2012). Others allowed cases to remain open longer. In the states that had timelines, there were provisions for extensions when required. 

Cases may be closed for a variety of reasons. Based on 2017 NAMRS reporting from 19 states, half of cases were closed because the investigation was completed, 29.3% of cases were closed because the investigation/protective services were completed, or for another closure reason (7.2%). States also reported closing cases even if the investigation had not been completed, due to client refusal (2%), client death (1.5%), client decision (1.7%), or nonspecific reasons (4.9%; Aurelien et al., 2018b).

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Domain 3. Receiving Reports of Maltreatment

Encompasses elements related to how reports of alleged adult maltreatment should be received and what information should be collected and how it should be used to initiate the investigation:

Intake

Screening, prioritizing, and assignment of screened-in reports

Key recommendations include:

Intake should be open 24/7 and fully accessible.

Intake workers should be APS workers.

Screening, triaging, and case assignment protocols should be standardized across the APS program.

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The intake process must be easy and fully accessible to those needing to make a report and must include collection of essential data to facilitate an appropriate, timely, and helpful response to the alleged victim. 

The APS Survey revealed that 75% of states had intake lines for reporting alleged adult maltreatment 24 hours a day, 68% of which were staffed. Other 24-hour intake lines used contracted call centers, a message service, or online services during nonbusiness hours. In states without a 24-hour intake line, callers were urged to contact law enforcement to report maltreatment (National Adult Protective Services Association [NAPSA] & National Association of States United for Aging and Disabilities, 2012). 

Recent data (2017) from the National Adult Maltreatment Reporting System shows that 51.9% of states provide a centralized statewide hotline or call-in number as a single point of entry for reports of maltreatment. Approximately a quarter of states (24.1%) provide a combination of both statewide and local hotlines or call-in numbers, and 20.4% provide decentralized regional or county hotlines or call-in numbers only (Aurelien et al., 2018a). 

Screening is a process of carefully reviewing the intake information to determine if the report should be screened in for investigation, screened out, or referred to a service or program other than APS. 

Risk factors are identified to determine the urgency for commencing investigation of screened reports. 

Nearly all states reported prioritizing reports screened in for investigation and having required time frames for APS response associated with identified risk levels. 

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Domain 4. Conducting the Investigation

Encompasses elements related to determining if maltreatment has occurred:

Conducting a psychosocial assessment

Investigations in residential care settings

Completing the investigation and determining the finding

Key recommendations include:

All types of maltreatment should be noted and investigated.

The investigation may continue, but the client has the right not to participate in it.

Use of multidisciplinary teams is encouraged.

Standardized screening tools for decision-making capacity and maltreatment are encouraged.

Acceptance of APS services is voluntary (except in certain cases).

Workers should have received training to investigate circumstances described in report (e.g., reports in residential facilities).

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To ascertain whether maltreatment has occurred, information is gathered through interviews with the client, the alleged perpetrator, and other involved parties, and through review of relevant documents and records. 

Some programs use a structured decision-making tool to standardize the collection of information and guide the investigator in evaluating collected evidence through an objective and more detailed approach.

For instance, substantiation rates have shown to be higher with the use of the technology-based Elder Abuse Decision Support System (EADSS) full interview guide and short-form measures, compared to APS protocols (Beach et al., 2017; Conrad, Iris, & Liu, 2017). 

However, standardized tools should not preclude staff from approaching clients creatively to explore ways to reduce the risk of harms the client faces and engaging clients who say they do not want services. 

The APS assessment is key in collecting information about the vulnerable adult’s overall situation. 

The purpose of the assessment is to determine the services or actions needed for the vulnerable adult to be safe and remain as independent as possible. 

Based on the 2017 National Adult Maltreatment Reporting System (NAMRS) data, 75% of states use a common instrument or tool throughout the state to conduct assessments. For other states (25%), assessment instruments are determined by each county or left to the worker’s discretion (Aurelien et al., 2018a). 

Because adult maltreatment may have a traumatizing effect on the alleged victim, it is important that APS programs utilize principles of trauma-informed care in order to facilitate a respectful and sensitive approach to working with the alleged victim, starting with the APS client assessment.

Based on 2017 NAMRS data, in 38 states, APS investigates allegations of maltreatment when they occur in at least some type of “residential facilities”; in 14 states, APS never investigates allegations of maltreatment in facilities (Aurelien et al., 2018a). 

APS systems that are responsible for investigating and intervening in cases of maltreatment in residential care facilities carry the burden of ensuring that their staff are trained and are receiving supervision and consultation on the specific issues that can arise in these cases. 

These issues include clinical, forensic, and legal considerations, such as the possibility that multiple residents have been harmed when an abusive employee, resident, or visitor has had access to vulnerable residents. 

Special skills and approaches are often required in residential care cases, including exercising caution to avoid escalating danger to those involved (Ramsey-Klawsnik & Teaster, 2012).  

The NAPSA Minimum Standards recommend protocols that establish a standard of evidence to be applied when investigation conclusions are reached. 

Typically, APS systems apply the “preponderance of evidence” standard requiring that at least slightly more than half of the evidence supports an allegation to substantiate it. This standard is very different from the “clear and convincing” and “beyond a reasonable doubt” standards typically applied in criminal situations (Ramsey-Klawsnik, 2015). 

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Domain 5. Service Planning and Service Implementation

Encompasses elements related to assessing the need for and delivering services to clients: 

Voluntary service implementation

Involuntary service implementation 

Closing the case

Key recommendations include:

Intervene as early as possible.

Target services to the kinds of abuse experienced.

Consider longer-term interventions (building alliances).

Prioritize services that break down isolation.

Services should be monitored until a case is closed.

Success is defined by the client.

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APS is a voluntary service, and its interactions with clients are based on principles of ethical practice including, but not limited to, person-centered planning, least restrictive alternatives, and supported decision-making. 

After APS has completed the investigation and the client assessment, in many states a service plan is created with the client. 

The goal of the service plan is to improve client safety, prevent maltreatment from occurring, and improve the client’s quality of life. Service plans are monitored, and changes can be made, with the client’s (or their designated representative’s) involvement, to facilitate services that address any identified shortfalls or newly identified needs and risks. The service plan will include the arrangement of essential services as defined in statute or policy. 

APS systems are sometimes called on to provide services in cases where there has been a determination of extreme risk and the client lacks capacity or cannot consent to services .

Safety goals should be balanced with the right, preferences, and self-determination of the client, making case resolution an intrinsically subjective and multilayered outcome. Thus, goals toward case closure should be specific to each client and should be contingent on clients’ attainment of their specific goals (Burnes, Connolly, Hamilton, & Lachs, 2018). 

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Domain 6: Training

Encompasses elements related to hiring, onboarding, maintaining, and supporting the APS workforce. 

Case Worker and Supervisor Minimum Educational Requirements

Case Worker Initial and Ongoing Training

Supervisor Initial and Ongoing Training

Key recommendations include: 

Workers should have at least a BA/BS degree, and preference should be given to those with a Master’s degree.

Training has four components: orientation, supervised fieldwork, core competencies, and advanced or specialized training.

Supervisors should be trained in supervisory skills within the first year of acting as a supervisor.

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Research indicates that higher education requirements for workers lead to higher substantiation of allegations. In one study, requiring a social work education background led to higher investigation and substantiation rates (Jogerst et al., 2004). Investigation rates were significantly higher when the state required that staff have a social work degree; however, substantiation ratios were significantly lower in these same states (Daly et al., 2005). 

It is in the best interest of clients that APS caseworkers receive initial and on-the-job training in the core competencies of their challenging job. For instance, research has shown that differing interpretations of definitions of confirmed, inconclusive, and unfounded case findings, along with differences in worker skill, expertise, and training, may contribute to variability in APS case decisions on allegations and findings (Mosqueda et al., 2016). 

Studies indicate that training improves staff knowledge, confidence, self-perceived skills, and perceived competence in delivering APS, and it leads to change in practice (DuMont, Kosa, Yange, Solomon, & Macdonald, 2017; Pickering, Ridenour, Salaysay, Reyes-Gastelum, & Pierce, 2018; Storey & Prashad, 2018), as well as increased rates of investigation and substantiation of maltreatment reports (Connell-Carrick & Scannapieco, 2008; Jogerst et al., 2004; Turcotte, Lamonde, & Beaudoin, 2009). Importantly, these improvements have shown to be significant when comparing outcomes for APS workers who did and did not complete trainings (Storey & Prashad, 2018). 

Given the potentially hazardous work environment and negative impact on job satisfaction, work stress, and health outcomes (physical and mental) for APS workers, it is essential that supervisors have the tools to build positive and supportive work environments. These tools may include management strategies for the prevention of burnout and secondary traumatic stress (Ghesquiere et al., 2018). 

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Domain 7: Program Performance

Encompasses elements related to collection and management of program data and evaluation of program performance:

Managing Program Data

Evaluating Program Performance

Key recommendations include:

Data should be congruent with NAMRS and should be kept long enough to ensure their availability for quality assurance efforts.

Programs should compile a written report on the program’s performance; performance measures should include timeliness as well as client-centered outcomes.

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APS programs can only be as effective as their individual practices and procedures. Thus, evaluation of program performance and well-designed research assessing the impact of specific practices on APS clients and workers are key to identifying best practices for the field. 

APS research has grown significantly over the past few years, with studies focusing on a variety of topics, such as client satisfaction (Booker, Breaux, Abada, Zia, & Burnett, 2018), factors that predict alleviation of risk in APS clients (Burnes et al., 2014), and APS workers’ perceptions of repeated referrals and recidivism to APS (Susman et al., 2015). However, well-designed research is still much needed to demonstrate the effectiveness of APS programs and practices in improving client outcomes and supporting APS workers and supervisors do their best work. 

Program data serve a key role in telling the story of the important work of APS, and effective data management is a key for ensuring the story is accurate. Significant variability exists in data collection and management across the nation. For example, some states keep case data for up to 10 years; other states purge data at 6 months, or 1 to 2 years. 

The process of evaluating APS programs’ performance has several goals. First, it provides information on how the program helps its clients. Second, it provides information that helps workers and supervisors do their best work. Third, it provides the APS program with information it can use to tell a compelling story about the program and its effectiveness to decision-makers, other providers, and the community as a whole. 

The APS Survey reveals that 43 states have developed benchmarks and metrics for program evaluation (NAPSA & National Association of States United for Aging and Disabilities [NASUAD], 2012). Generally, however, annual evaluations of program performance are not a standard tool in each state’s program. Only 17 states reported publishing an annual APS report, with the details of each report varying greatly. 

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The Process for Updating the APS Guidelines

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Process of Updating the Guidelines

Phase I – Reviewed new research

Updated literature review (2014–2018)

Drafted proposed updates based on new research

Phase II – Engaged the field and the public

Engaged stakeholders through 5 webinars and Request for Information

Analyzed stakeholder feedback and created report

Prepared feedback for review by a technical expert panel (TEP)

Phase III – Consulted the experts

Held five TEP virtual working meetings

Updated Guidelines based on TEP decisions 

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As part of the Guidelines updates, ACL identified several key objectives: 

Determine appropriate updates to the Guidelines. 

Identify additional topics for inclusion in the Guidelines as needed. 

Identify topic areas for which research on APS practices is lacking. 

Determine how frequently ACL should re-engage stakeholders in the process to update the Guidelines, and gather ideas on the most efficient way for stakeholders to provide input. 

Similar to the development of the original version of the Guidelines, ACL applied a multistep approach for updating the Guidelines, with each step building onto the work from the previous step. These steps include:

an updated literature review to identify new research evidence;

draft revisions and additions to the Guidelines based on new research evidence;

a stakeholder engagement process to obtain feedback for the proposed updates;

A comprehensive data analysis of the feedback received from stakeholders;

a detailed synthesis of the results; and finally

convening a TEP to refine and build consensus for the updates based on the proposed updates and feedback from stakeholders.

The slides below provide more detailed information on all of these phases.

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Phase I: Reviewed New Research

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Literature Search: Methods and Results

Updated literature search: April 2014  November 2018

Searched 13 databases 

Results/Implications: 

24 peer-reviewed journal articles

Research relevant to 6 out of 7 Guidelines domains (nothing relevant to Domain 3: Receiving Reports of Maltreatment)

Several studies had findings that impacted several domains

Actions taken: Added text to background only (but did not change guidance); or added text to background and changed guidance 

None of the original guidance was deleted

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Purpose: The purpose of the literature search and review was to identify new evidence published in peer-reviewed journal articles focused on the evaluation of APS programs and practices. 

Time frame: The new literature search captured studies published between April 2014 and November 30, 2018.

Search terms: abuse, adult protective service, adults with disabilit*, disabled, elder, exploitation, fraud, maltreatment, mistreatment, neglect, older adult, outcomes, or vulnerable 

Inclusion criteria: published in English; contains quantitative data analysis or presents literature review; related to or applicable to APS programs, operations, practices, and processes 

Selection: To determine if articles met the purpose and the inclusion criteria for this review, titles and narrative descriptions of identified articles were screened first. Subsequently, abstracts were reviewed to identify relevant articles, and of those deemed relevant after abstract review, full articles were reviewed and key information was extracted. 

Categorization: Findings from the included articles were reviewed and cross-walked with the domains and elements addressed by the Guidelines. Articles were then categorized based on the domain and elements they addressed, i.e., which domain(s) and element(s) may be supported, updated, or revised based on the article’s findings. 

Results

The findings from the 24 included studies were relevant to all but one of the seven Guidelines domains. None of the findings were relevant to domain 3 (Receiving Reports of Maltreatment). The majority of studies were related to domain 1 (Program Administration), and within that domain, most studies (N=5) were related to element 1e (Coordination With Other Entities). Seven articles were relevant to domain 5 (Service Planning and Service Implementation); of those, five addressed element 5a (Voluntary Service Implementation). Five articles were relevant to domains 4 (Conducting the Investigation) and 6 (Training) respectively. 

Eighteen of the 24 studies included data from clients served by APS (N=16) or CPS (N=2). For those studies focused on APS client data, three focused on clients 65 and older, 10 focused on clients 60 and older, one focused on clients 55 and older, one focused on clients 18 and older, and one focused on clients 65+ and dependent adults, aged 18–64, who were living in the community. The clients in all but one of these studies were identified by age specifically, without information regarding the clients’ disability status. Only one study specifically mentioned dependency as a qualifying criterion for the APS program. 

Use of the Findings

The findings from the literature review were used to inform draft updates and revisions to the 2016 Guidelines domains and elements. Specifically, findings from recently published studies were used to support the guidance statements and/or inform revisions or updates to the background and guidance statements in the elements. As noted, the findings had implications for all but one of the Guidelines domains. For the six relevant domains, the articles’ findings were used to make revisions by either adding text to the background but not changing the guidance statements or adding text to the background and changing the guidance statements. There were no cases where current guidance was deleted. It is important to note that several studies had findings that impacted several domains. 

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Studies focused on:

Service variables – coordination with other professions,  use of MDTs/Forensic Centers

APS procedures – using a decisional support system, adding mental health screening, using goal-attainment scaling

Client outcomes – mistreatment status at case closure, rate of return to APS system, client satisfaction

Investigation outcomes – rates of service refusal, rates of substantiation, rates of prosecution

Training outcomes – measuring knowledge, competence

APS worker outcomes – job satisfaction, secondary trauma levels, hazard exposure

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The 24 identified articles focused on six different themes shown here. Findings from the studies were integrated into the Guidelines where appropriate.

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Phase II: Engaged the Field and the Public

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The 2016 Guidelines were developed with extensive input from stakeholders representing multiple professional fields, including staff from APS, aging, long-term care, disability, domestic violence, sexual assault, and victim services networks; legal services and law enforcement; native and tribal communities; and federal staff. Members of the public also provided feedback. 

The goals of the stakeholder engagement and outreach process were to hear from all stakeholders about their experiences with APS, ensure all stakeholders understand why and how ACL is leading the development of Guidelines for APS, and provide interested parties an opportunity to give input into the process and content of the Guidelines. 

Throughout the process, ACL’s stakeholder engagement and outreach endeavored to 

respect people’s history and experience with APS, and their other life experiences; 

empower the public and stakeholders to contribute to the development of national APS guidelines in a meaningful way; 

understand the public’s vision for APS and for ACL’s role in APS; 

build consensus on proposed guidelines by including representatives from materially affected and interested parties, to the extent possible; and 

incorporate a civil rights/personal rights perspective in developing the system guidelines. 

For the updates, the public as well as professionals who may report and/or respond to abuse, neglect, and financial exploitation experienced by older adults and adults with disabilities were invited to provide feedback for the draft updates to the Guidelines via two main methods, a public comment period and stakeholder webinars. 

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Public Comment Period

ACL Request for Information Web page and email 

March–May 2019 

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Stakeholders were invited to provide feedback for the proposed updates to the Guidelines via the ACL’s request for information (RFI) Web page and direct e-mail. 

The Web page was publicly available and included information about the project and key materials (i.e., the Guidelines, suggested revisions and/or additions, literature references). 

Stakeholders had the opportunity to provide feedback via the ACL RFI Web page from the end of March until the end of May 2019. 

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Stakeholder Webinars

Hosted 5 webinars: Approximately 190 stakeholders, representing 39 states and D.C., and representing 10 fields (the majority from APS) participated.

How familiar are you with the APS Guidelines?
| Familiarity         | Percentage |
|---------------------|------------|
| Extremely familiar  | 3%         |
| Very familiar       | 32%        |
| Somewhat familiar   | 30%        |
| Slightly familiar   | 24%        |
| Not at all familiar | 10%        |

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Stakeholders were invited to provide feedback via webinars. Five webinars were held during April and May 2019. 

The webinar platform allowed for the presentation of visual content (draft revision), polling, and written comments by participants. 

As part of the webinar registration, stakeholders were asked to indicate the state and field they represented. 

During the webinar, participants were encouraged to respond (voluntarily) to the following polling questions: 

What professional group are you representing today?

Before preparing for today’s call, how familiar were you with the current National APS Guidelines?

How frequently should the Guidelines be updated in the future?

Webinar Participants

Approximately 190 people attended. 

Those in attendance represented 39 state sand DC.  

While the majority of webinar attendees were APS workers or administrators, 9 other professions were also represented (e.g., people from the disability rights community, long-term care professionals, legal aide).    

62% said they were either somewhat or very familiar with the Guidelines, while 10% said they were not at all familiar; 3% judged themselves to be extremely familiar with them.

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Number of Comments 

278 comments were coded for relevant feedback:

216 comments related specifically to the content of the Guidelines (e.g., background and guidance).

62 comments concerned other topics related to the Guidelines  (e.g., formatting, frequency of updating dissemination).

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Stakeholders commented on the proposed updates as well as the original content.

For all comments received via the webinars and the public comment period, at total of 278 comments were coded as containing relevant feedback. 

Of those, 216 comments were related specifically to the content of the Guidelines (e.g., background and guidance). 

The feedback was related to supporting proposed updates or expressing concerns about proposed updates, challenges for implementing the Guidelines, recommendations for additional revisions for specific domains/elements, and global feedback regarding Guidelines (e.g., use of victim vs. client). 

Other comments (N=62) were coded as being related to feedback about aspects outside the content of the Guidelines. 

These included the format of the Guidelines, the frequency and process for updating the Guidelines, the dissemination of the Guidelines, and research gaps.  

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Comments by Domain

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Stakeholders provided comments for all seven domains, including domain 3, for which no updates were proposed. 

The majority of comments focused on Domain 1, Program Administration (28.2 %), followed by Domain 5, Service Planning and Intervention (24.8%), and Domain 6, Training (17.5%). 

One stakeholder provided a comment for Domain 3, Receiving Reports of Maltreatment. 

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Nature of the Comments

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As noted, 216 of the comments involved specific feedback regarding the proposed updates to the Guidelines. 

Specifically, stakeholders voiced support or agreement for the updates (12% of comments), expressed concerns or disagreement (3.2% of comments), noted challenges for their implementation (7.4% of comments), noted global comments (22.2% of comments), and provided specific recommendations for additional revisions (55.1% of comments). 

Recommendations were related to revising specific wording, adding additional content/wording, providing clarification.

The majority of the feedback included suggestions to add additional content or revise wording. 

These comments were all coded for use by the Technical Expert Panel.

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Phase III: Consulted the Experts

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Once the literature and comments from the stakeholder engagement period were collected and analyzed, we brought together a panel of experts in the field to apply real world wisdom and experience to the Guidelines.  A nine-person technical expert panel was convened.

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Role of the Technical Expert Panel

Review new research and its applicability to the APS Guidelines

Review stakeholder comments and determine applicability to the APS Guidelines

Identify items not revealed in research or public comments

Apply real world experience and wisdom: “the voice of the field”  

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Key Decisions by the TEP

Agreed with stakeholder recommendations 

Implemented recommendation: 29

Implemented with additional revisions or with alternative approach: 17 

Did not agree with stakeholder recommendations: 19

TEP-initiated revisions/additions: 16

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TEP members were invited to participate in five virtual meetings, each lasting 90 minutes. Prior to the first meeting, TEP members received an annotated bibliography of the new research to be considered as well as a copy of the Guidelines that included all proposed updates in track changes and comments showing the feedback received from stakeholders for each domain/element. 

As a result of discussions during virtual meetings, TEP members reached agreement about whether to make changes or not in response to stakeholder recommendations. TEP members also recommended revisions that were not related to stakeholder feedback.

The TEP decisions broke down as follows:

The TEP agreed with 36% of the stakeholder recommendations, and implanted those as provided

The TEP agreed with 21% of the stakeholder recommendations, but implemented recommendation with additional revisions or alternative approach 	

They did not agree with 23% of stakeholder recommendations. The TEP also suggested some revisions and additions of their own.

The TEP recommended and implemented revision/addition not related to stakeholder feedback (20%)	

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Final Updated Guidelines

https://acl.gov/programs/elder-justice/final-voluntary-consensus-guidelines-state-aps-systems

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With feedback from the field, the Guidelines were re-formatted to make the more use-friendly

The Guidelines document is now focused on the actual guidance; the guidance is highlighted uses yellow background 

Content regarding the development and literature are now provided in separated appendices

Use this link to access the Guidelines and appendices

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What’s Next?

ACL will update the Guidelines with new findings and stakeholder input at regular intervals.

The Guidelines are currently being used by ACL to inform technical assistance to a sample of pilot state APS administrators.  

As part of the pilot, states are identifying practice or policy changes they would like to make to better align with the Guidelines.

Alignment with the Guidelines as a measure of a “good” program?

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ACL has made a commitment to the field to update the Guidelines regularly (potentially every three years).  

ACL is also currently conducting a pilot to test effective strategies for delivering technical assistance to APS programs for integrating the Guidelines.

The results of this pilot study will help inform delivery of future technical assistance to APS programs on the Guidelines. In some circles, alignment of an APS program’s policies and practices with the Guidelines is being taken as a measure of what it means to be a “good “ APS program.

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Questions?

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Thank you!

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Contact Information

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References

AARP Public Policy Institute. (2011). Adult protective services: Increased demand and decreased funds [Fact sheet]. Retrieved from https://assets.aarp.org/rgcenter/ppi/ltc/fs212-ltc.pdf

Aurelien, G., Beatrice, M., Cannizzo, J., Capehart, A., Gassoumis, Z., & Greene, M. (2018a). FFY NAMRS 2017 Report 1: Agency Component. Submitted to the Administration of Community Living, U.S. Department of Health and Human Services.

Aurelien, G., Beatrice, M., Cannizzo, J., Capehart, A., Gassoumis, Z., & Greene, M. (2018b). NAMRS FFY 2017 Report 2: Key Indicators. Submitted to the Administration of Community Living, U.S. Department of Health and Human Services.

Beach, S. R., Liu, P.-J., DeLiema, M., Iris, M., Howe, M. J. K., & Conrad, K. J. (2017). Development of short-form measures to assess four types of elder mistreatment: Findings from an evidence-based study of APS elder abuse substantiation decisions. Journal of Elder Abuse & Neglect, 29(4), 229–253.

Booker, J. G., Breaux, M., Abada, S., Xia, R., & Burnett, J. (2018). Assessment of older adults' satisfaction with adult protective services investigation and assistance. Journal of Elder Abuse & Neglect, 30(1), 64–74.

Burnes, D., Connolly, M. T., Hamilton, R., Lachs, M. S. (2018). The feasibility of goal attainment scaling to measure case resolution in elder abuse and neglect adult protective services intervention. Journal of Elder Abuse & Neglect, 30(3), 209–222.

Burnes, D. P. R, Rizzo, V. M., & Courtney, E. (2014). Elder abuse and neglect risk alleviation in protective services. Journal of Interpersonal Violence, 29(11), 2091–2113.

Connell-Carrick, K., & Scannapieco, M. (2008). Adult protective services: State of the workforce and worker development. Gerontology & Geriatrics Education, 29(2), 189–206.

Conrad, K. J., Iris, M., & Liu, P.-J. (2017). Elder abuse decision support system: Field test outcomes, abuse measure validation, and lessons learned. Journal of Elder Abuse & Neglect, 29(2–3), 134–156.

Daly, J. M., Jogerst, G. J., Haigh, K. M., Leeney, J. L., & Dawson, J. D. (2005). APS workers job requirements associated with elder abuse rates. Social Work in Health Care, 40(3), 89-–02.

Du Mont, J., Kosa, D., Yang, R., Solomon, S., & Macdonald, S. (2017). Determining the effectiveness of an elder abuse nurse examiner curriculum: A pilot study. Nurse Education Today, 55, 71–76.

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References, cont’d

Ghesquiere A., Plichta, S. B., McAfee, C., & Rogers, G. (2018). Professional quality of life of adult protective service workers. Journal of Elder Abuse & Neglect, 30(1), 1–19.

Jogerst, G. J. J., Daly, J. M., Dawson, J. D., Brinig, M. F., Schmuch, G. A., & Peek-Asa, C. (2004). APS investigative systems associated with county reported domestic elder abuse. Journal of Elder Abuse & Neglect, 16(3), 1–17.

Mosqueda, L., Wiglesworth, A., Moore A. A., Nguyen, A., Gironda, M., Gibbs, L. (2016). Variability in findings from adult protective services investigations of elder abuse in California. Journal of Evidence-Informed Social Work, 13(1), 34–44.

National Adult Protective Services Association & National Association of State Units on Aging. (2012). Adult protective services in 2012: Increasingly vulnerable. Retrieved from http://www.napsa-now.org/wp-content/uploads/2012/06/BaselineSurveyFinal.pdf

Pickering, C. E. Z., Ridenour, K., Salaysay, Z., Reyes-Gastelum, D., & Pierce, S. J. (2018). EATI Island: A virtual reality- based elder abuse and neglect educational intervention. Gerontology & Geriatrics Education, 39(4), 445–463.

Ramsey-Klawsnik, H. (2015). Investigation protocols [National Adult Protective Services Resource Center technical assistance brief]. Retrieved from http://www.napsa-now.org/wp-content/uploads/2015/03/TA-Brief-Invesitgation-Protocols.pdf

Ramsey-Klawsnick, H., & Teaster, P. (2012). Sexual abuse happens in healthcare facilities: What can be done to prevent it? Generations, 36(3), 53–59.

Storey, J. E., & Prashad, A. A. (2018). Recognizing, reporting, and responding to abuse, neglect, and self-neglect of vulnerable adults: An evaluation of the re:act adult protection worker basic curriculum. Journal of Elder Abuse & Neglect, 30(1), 42–63.

Susman, A., Lees, K. E., & Fulmer, T. (2015). Understanding repeated visits to adult protective services. The Journal of Adult Protection, 17(6), 391–399.

Teaster, P. B., Dugar, T., Mendiondo, M., Abner, E. L. , Cecil, K. A., & Otto, J. M. (2006). The 2004 survey of adult protective services: Abuse of vulnerable adults 18 years of age and older. Washington, DC: National Center on Elder Abuse.

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