Appendix 2 

APS Literature Annotated 

Bibliography: 2004-2018 

September 23, 2019 

Prepared for 

Administration for Community Living 

Offce of Performance and Evaluation 

Submitted by 

New Editions Consulting, Inc. 

The Lewin Group 
2 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	

Contents 

Literature Search Methods 3 

Guidelines Updates 3 

2016 Guidelines 3 

Literature Search Findings 3 

1. PROGRAM ADMINISTRATION 4 

2. TIME FRAMES 10 

3. RECEIVING REPORTS OF MALTREATMENT 10 

4. CONDUCTING THE INVESTIGATION 11 

5. SERVICE PLANNING AND SERVICE IMPLEMENTATION 13 

6. TRAINING 16 

7. APS PROGRAM RERFORMANCE 19 

References 20 

To see the updated Guidelines, go to: https://acl.gov/programs/elder-justice/final-voluntary-consensusguidelines-state-aps-systems.
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 3

	 	

	 	

Literature Search Methods 

In 2016, the frst National Voluntary Consensus Guidelines for State Adult Protectives Services (APS) 

Systems (Guidelines) was developed by the Administration for Community Living (ACL). In 2018, ACL 

initiated the process for updating the Guidelines. The literature review in both 2016 and 2018 sought to 

identify peer-reviewed journal articles focused on the evaluation of APS programs and practices. Although 

the main focus for the literature searches was on studies reporting fndings for APS, studies reporting on 

effective protective service strategies from the child welfare feld and long-term care ombudsman programs 

were also reviewed if those service strategies applied to the APS feld as well. 

Guidelines Updates 

For the current Guidelines updates, a search was conducted for articles published between April 1, 2014, 

and November 30, 2018, searching 14 databases (i.e., Applied Social Sciences Index and Abstracts, 

Dissertations Abstracts, EBSCOhost Academic Search Complete, EBSCOhost MEDLINE Complete, ERIC, 

Google Scholar, Lexis-Nexis U.S. Law Reviews and Journals, National Criminal Justice Reference Service 

Abstracts Database, PILOTS: Published International Literature on Traumatic Stress, PubMed, Sage 

Publications Database, ScienceDirect, Social Services Abstracts, Sociological Abstracts). The following 

keywords were used for the search: abuse, adult protective service, adults with disabilit*, disabled, elder, 

exploitation, fraud, maltreatment, mistreatment, neglect, older adult, outcomes, or vulnerable. 

2016 Guidelines 

For the 2016 Guidelines, a search was conducted for articles published between 2004 and March 2014, 

searching 12 databases (the same databases as for the updates, except PubMed and ScienceDirect), and 

using keywords including search terms such as abuse, fraud, exploitation, maltreatment, adult protective 

service, elder, disabled, and outcomes. 

Literature Search Findings 

The following section provides a summary listing of articles (annotated bibliography) identifed through 

the two literature searches conducted to date for the APS Guidelines. All articles are listed alphabetically 

by author under the relevant Guidelines domain and elements, based on the relevance of the fndings. 

(Note: articles/fndings may be relevant to more than one domain and, therefore, may be listed more than 

once.) Given that the primary focus of the current effort is on new research for the 2019 Guidelines update, 

relevant articles identifed through the 2014–2018 search are presented frst, followed by articles identifed 

through the initial 2004–2014 search. 
4 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	

	 	 	 	 	

	 	

1C. DEFINITIONS OF MALTREATMENT 

	 	

	 	 1E. MANDATORY REPORTERS 

1. PROGRAM ADMINISTRATION 

1A. ETHICAL FOUNDATION OF APS PRACTICE 

No new supporting research identifed. 

1B. PROTECTING PROGRAM INTEGRITY 

No new supporting research identifed. 

Mosqueda et al. (2016) conducted a formative evaluation to assess and understand the variability 

in elder abuse case fndings in California by interviewing APS workers. In California, each county’s 

APS offce reports detailed data on APS investigations to the state department of social services 

monthly using a document called the SOC 242. Each allegation of abuse or neglect is investigated 

by an APS worker to determine whether it is “confrmed,” “inconclusive,” or “unfounded.” The SOC 

242 provides defnitions of these terms, but the defnitions are not precise. Results showed that the 

number of completed investigations by each county varied widely and that there was a wide range in 

the percentage of confrmed, inconclusive, and unfounded cases. APS workers noted that the limited 

defnitions of the terms allow for a wide variety of interpretations of their meaning. APS workers also 

noted that variations in individual levels of skill, experience, and training can infuence personal 

decisions on allegations and fndings. Others noted the need for training to improve consistency 

and accuracy for identifying types of allegations. Interviewees who were APS employees with prior 

experience in child protective services (CPS) revealed a bias toward “unfounded” fndings. Some 

respondents stated that the perceived impact on resource allocation infuenced social workers’ 

conclusions. Since “unfounded” fndings may not warrant the allocation of services, workers who 

identify a need for the elder or family to access services, despite an absence of abuse, may be biased 

toward issuing an inconclusive fnding. Many APS workers also expressed that it was sometimes 

diffcult to make a clear determination of capacity. The authors conclude that differing interpretations 

of defnitions of confrmed, inconclusive, and unfounded case fndings, along with differences in worker 

expertise and practices, are the major contributors to variation in elder abuse data. 

1D. POPULATION SERVED 

No new supporting research identifed. 

Lees (2018) examined associations between mandated reporting and APS case outcomes using 

administrative data from the Massachusetts APS system, collected between June 2015 and March 

2016. Reporters of abuse and neglect were categorized as mandated health care professional, 

other mandated reporter, or nonmandated report. A total of 17,081 individuals were included in the 

fnal dataset. Results showed that more than half of the reports were made by mandated reporters 

(59%), of whom 24% were classifed as health care professionals. Controlling for victim age, gender, 

residence, and the primary allegation type, there was no signifcant effect of mandated status on 

whether a case was screened in. The results showed a signifcant effect of mandated status on 

case substantiation, with reports made by mandated reporters having 1.26 times the odds of being 

substantiated compared to those made by nonmandated reporters. In addition, examination of the 

infuence of the covariates showed that reports made on victims in the younger age groups (60–79) 

were more likely to be substantiated than those made on victims who were aged 80–89. Reports made 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 5

	 	 	 	

1F. COORDINATION WITH OTHER ENTITIES 	 	 	

	 	 	 	

 

on victims in the eldest age group (90+-year-olds) were less likely to be substantiated than those made on 

80–89-year-olds. Reports that included allegations of physical and/or sexual abuse were more likely to be 

substantiated compared to those made for emotional abuse or neglect and less likely to be substantiated 

compared to reports with the primary allegation of self-neglect. Results also showed that reports made by 

nonmandated reporters had 1.27 times the odds of service refusal compared to those made by mandated 

reporters. Allegations of neglect and self-neglect were less likely to be associated with service refusal 

compared to allegations that included physical and/or sexual abuse. Reports from nonmandated reporters 

and health care professionals were less likely to be substantiated compared to reports made by other 

types of mandated reporters. Lastly, reports from nonmandated reporters were statistically signifcantly 

more likely to result in service refusal compared to those made by mandated reporters who were not 

health care professionals. In conclusion, the study found that reports made by mandated reporters 

were more likely to be substantiated and less likely to result in service refusal than reports made by 

nonmandated reporters. 

Mathews, Lee, and Norman (2016) assessed the impact of a new mandatory reporting law in Western 

Australia for reporting child sexual abuse (CSA) on the number of reports made and the outcome of 

those reports. To assess the impact of the law, the authors compared the number of suspected child 

maltreatment reports made by mandated reporters and outcomes of those reports before the law (2006– 

2008) and after the law (2009–2012). The three main subgroups of mandated reporters used for analyses 

were police, teachers (including school principals), and doctors. Results showed that the number of reports 

by mandated reporters of suspected child sexual abuse increased by a factor of 3.7, from an annual mean 

of 662 in the 3-year prelaw period to 2,448 in the 4-year postlaw period. The increase in the frst 2 postlaw 

years was contextually and statistically signifcant. The rate of reporting stabilized in 2010–2012, at one 

report per 210 children. The number of investigated reports increased threefold, from an annual mean of 

451 in the prelaw period to 1,363 in the postlaw period. There was a signifcant decline in the proportion of 

mandated reports that were investigated in the frst 2 postlaw years, suggesting the new level of reporting 

and investigative need exceeded capacity. The authors suggest that the subsequent signifcant increase 

in investigation in the third year, to the prelaw levels, suggests systemic adaptive capacity. The number 

of substantiated investigations doubled, from an annual mean of 160 in the prelaw period to 327 in the 

postlaw period, indicating twice as many sexually abused children were being identifed. The authors 

conclude that the mandatory reporting law for CSA is associated with a substantial and sustained increase 

in identifcation of cases of CSA. 

Gassoumis, Navarro, and Wilber (2015) conducted a quasiexperimental study to examine the extent to 

which the elder abuse forensic center (forensic center) model, compared to usual APS care, increases 

the odds of conservatorship as a means to improving the safety of victims of elder fnancial exploitation 

(using propensity score matching). The outcomes for this study were whether APS cases were referred 

to a public guardian (PG) and whether clients were conserved. Findings indicate that the forensic center 

team had seven times greater odds of referring cases to the PG. While the proportion of cases referred 

by the center that resulted in conservatorship was not signifcantly different from the proportion in the 

usual care group, there were signifcantly more conservatorships among cases heard at the forensic 

center due to the higher rate of referral. The authors suggest that the magnitude of the observed effects 

indicates that the forensic center offers an effective pathway in bringing cases to the PG’s attention for 

investigation and conservatorship, thereby increasing conservatorship as a remedy for those who require 

the highest level of protection. 
6 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	

	 	 	 	

	 	 	

He and Phillips (2017) conducted a secondary data analysis to assess the impact of interagency 

collaboration between child welfare (CW) and drug and alcohol services (DAS) on service delivery. The 

authors used data from the second cohort of families from the National Survey of Child and Adolescent 

Well-Being (NSCAW II). Results showed that having a memorandum of understanding (MOU) was the most 

prevalent collaboration activity (60%) between CW agencies and DAS providers. This was followed by 

cross-training (41%) and colocation of staffs and joint budgeting (29%). Around 60% of the CW agencies 

reported engaging in only one or no collaboration strategies with DAS providers. About 40% of the CW 

agencies reported that they always or sometimes had the availability of substance abuse specialists to 

accompany CW social workers during child abuse and neglect investigations. Approximately one third 

of the agencies reported that they had adequate to very adequate substance abuse treatment services 

available to families, whereas slightly fewer than 60% reported that they had priority arrangements for 

treatment for CW-involved families dealing with substance use disorders (SUDs). The mean total number of 

available SUD-related resources was 1.65 (SD = 0.23); 21% of the CW agencies reported that they did not 

have any availability of SUD-related resources in their organization. Results also indicated that availability 

of SUD resources was greater in CW agencies that engaged in the collaboration strategy of having an MOU 

and colocation of staffs, after accounting for all other covariates. Additionally, more intense collaboration 

was signifcantly associated with greater availability of SUD-related resources. 

Rizzo, Burns, and Chalfy (2015) evaluated a multidisciplinary intervention model to address elder 

mistreatment, integrating the expertise of social workers and lawyers under the same roof, namely, the 

Jewish Association Serving the Aging (JASA) Legal/Social Work Elder Abuse Prevention Program (LEAP) in 

New York City. Data were generated using systematic random sampling (n = 250) from a multisite sample 

of JASA-LEAP case records closed between 2009 and 2011. Findings indicated that clients who accepted 

JASA-LEAP services were more likely to experience a reduction in risk of future mistreatment upon case 

closure. Findings also revealed that higher levels of JASA-LEAP intervention model fdelity were associated 

with more favorable outcomes at case closure—evidence that the program is working. The authors suggest 

that the fndings from this study support the use of multidisciplinary models to intervene with victims of 

elder mistreatment. 

Sirey et al. (2015) conducted a pilot study to examine the feasibility of implementing routine screening 

for depression and anxiety into an elder abuse service system; test the acceptability of a mental health 

intervention called Providing Options to Elderly Clients Together (PROTECT) to improve depression and elder 

abuse outcomes; and determine the most acceptable format to deliver mental health services within elder 

abuse practice. Three different delivery strategies were used: mental health and abuse services provided by 

the same counselor (“combined”); mental health and abuse services provided by different counselors who 

shared the client (“shared”); and standard referral (“referral”) to nearby mental health services, which was 

the usual procedure. Participants for this pilot were older adults (age ≥ 60) receiving services from the New 

York City Department for the Aging’s Elderly Crime Victims Resource Center (ECVRC). For the screening, 

ECVRC integrated depression and anxiety screening into routine case assessment, during the initial 

evaluation. Individuals with clinically signifcant depression or anxiety were randomized to receive one 

of the three mental health strategies (combined, shared, or referral). The PROTECT intervention included 

problem-solving psychotherapy, anxiety management techniques, and psychoeducation about the impact 

of depressive and anxious symptoms in general, as well as the potential impact of symptoms on taking 

steps to resolve the mistreatment. Staff screened 315 individuals, with 34% of clients scoring positive for 

depression or anxiety. Of those with mental health needs, only 15% refused all services. PROTECT was 

successfully implemented in two different formats with collaboration between staff workers. The results 

suggest that clients are willing to accept an offer of additional mental health services at the same time that 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 7

	 	 	 	

	 	 	 	

	 	 	 	 	 	 	

	 	 	 	

		 	

	 	 	

they are receiving mistreatment resolution service. Additionally, the pilot data support the potential for 

elder abuse service providers to work in tandem with mental health clinicians. 

Wilber, Navarro, and Gassoumis (2014) examined the effectiveness of a multidisciplinary team (MDT) 

intervention—the Los Angeles County Elder Abuse Forensic Center (Center). The authors used a 

quasiexperimental design, focusing on elder abuse cases involving victims aged 65 or older reviewed 

at the Center between April 1, 2007, and December 31, 2009. Center cases (n=287) were compared to a 

propensity-score-matched sample of APS cases. Comparison sample selection included all APS referrals 

aged 65 and over received by Los Angeles County’s APS during the study period (n=33,650), excluding 

any cases heard at the Center. Cases reviewed at the Center were signifcantly more likely to be submitted 

to the district attorney (22%) than the comparison APS cases (3%). The proportion of cases in which the 

district attorney then fled charges did not differ signifcantly (73% for the center cases versus 86% for the 

APS group), nor did the proportion of cases with a successful plea or conviction (92% for the center cases 

versus 100% for the APS group). Cases reviewed at the Center were signifcantly more likely to be referred 

to the Offce of the Public Guardian (30.6%) than usual care APS cases (5.9%). The proportion of referred 

cases that needed conservatorship did not differ signifcantly between the Center (52.9%) and the APS 

cases (41.7%). Recurrence of elder abuse was signifcantly reduced in Center cases, from 42.7% at baseline 

to 24.6%. By contrast, usual care APS cases showed a small but nonsignifcant increase in recurrence, 

from 16.7% at baseline to 20.3%. The authors conclude that the elder abuse forensic center MDT model is 

an effective approach as it signifcantly increased prosecution rates and conservatorships for cognitively 

impaired older adults and reduced the rate at which cases reentered the APS system. 

Supporting research from the 2016 Guidelines 

Navarro, Gassoumis, and Wilber (2013) studied the involvement of an elder abuse forensic center in 

fnancial exploitation cases. The team compared cases that involved the center with those following usual 

practice. The center’s cases were more often submitted to the district attorney, more often resulted in fling 

of charges, and increased the odds of establishing a perpetrator’s guilt. 

Wiglesworth, Mosqueda, Burnight, Younglove, and Jeske (2006) studied the impact of an elder abuse 

forensic center on collaboration of staff from multiple agencies in Orange County, California. Using surveys 

of agency staff, the team found participants believed they (the participants) were more effcient and 

effective when they collaborated with the forensic center. 

1G. PROGRAM AUTHORITY, COOPERATION, CONFIDENTIALITY, AND IMMUNITY 

No new supporting research identifed. 

1H. STAFFING RESOURCES 

No new supporting research identifed. 

Supporting research from the 2016 Guidelines 

Jogerst et al. (2004) studied the impact of various APS system characteristics on reports of abuse, 

investigations, and substantiated elder abuse. Data came from a survey of states. Investigators who 

handled reports of abuse of children and adults had lower investigation and substantiation rates than 

those who handled one or the other type of abuse report. 
8 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	 	 	 	

	 	 	 	 	

	 	 	

	 	 	 	 	

1I. ACCESS TO EXPERT RESOURCES 

Brink, Thackeray, Bridge, Letson, and Scribano (2015) conducted a retrospective study examining differences 

in child sexual abuse (CSA) determinations for 1,422 children who were assessed by a multidisciplinary 

team (MDT) and the local child protective services (CPS). The authors also examined factors associated 

with differences in determinations by the MDT and CPS. Results showed a moderate agreement between 

MDT and CPS determinations. Of the 997 cases determined by the MDT to have a high likelihood for 

abuse, 789 (79.1%) were substantiated or indicated by CPS. In cases where the MDT determined a low or 

indeterminate likelihood of abuse (425 patients), CPS did not substantiate or indicate CSA in 78.8% (335 

patients). High likelihood of CSA, as determined by the MDT, was strongly associated with an increasing total 

number of CSA disclosures and any disclosure of CSA, regardless of abuse severity. Other factors, such as sex, 

age, race, and socioeconomic status based on insurance type, were not associated with this determination, 

suggesting a nonbiased approach to the MDT determination of CSA. For cases with a high likelihood of CSA 

as determined by the MDT and CPS substantiation or indication, there was also a strong association with 

all risk disclosure categories of CSA. The authors suggest that the results highlight the importance of the 

forensic interview in CPS decisions of CSA and the potential role for child advocacy centers in providing 

trained professionals to conduct a high-quality interview during the initial assessment. 

Burnett, Dyer, Clark, and Halphen (2018) described the Texas Elder Abuse and Mistreatment Institute 

Forensic Assessment Center Network (TEAM-FACN) program as well as preliminary data from its 

implementation. The TEAM-FACN program uses a Web-based portal and low-cost videophone technology 

to connect an APS agency and its clients to a centralized geriatric and elder mistreatment expert medical 

team for virtual in-home assessments. The technology was used to conduct video-assisted assessments, 

including mental health assessments, and telephone-based protective service planning during 

interdisciplinary team meetings, and to provide consultation services. After launching the TEAM-FACN 

program, referrals increased signifcantly, suggesting that the program is effective in increasing access 

to geriatric and elder mistreatment expert assessments for APS cases. In addition, the authors suggest 

it can serve as a model for fostering state protective agencies and medical professional collaborations. 

The authors highlight that the technology makes it easier to gather data, access records, complete 

evaluations, and transmit reports, facilitating timely provision of assessments. In addition, it streamlines 

communication, makes the process quicker, and helps prevent unexpected process delays, such as reports 

being lost in the mail. The authors note that virtual assessments also increase timeliness and effciency 

by dissolving geographic barriers that limit expert availability and increase assessor travel time, and they 

offer a way to enhance collaborations. 

1J. CASE REVIEW SUPERVISORY PROCESS 

No new supporting research identifed. 

1K. WORKER SAFETY AND WELL-BEING 

Ghesquiere, Plichta, McAfee, and Rogers (2018) implemented a cross-sectional, anonymous Webbased and in-person survey of 321 APS workers and supervisors to assess their responses to APS work 

environments. Overall, 92.8% of respondents reported exposure to at least one hazard in their APS careers, 

and 71% reported exposure to one or more hazards in the past month. Respondents reported an average 

of 3.42 different hazard exposures in the past month, with the most common exposures being dangerously 

cluttered living spaces; garbage or spoiled food; insect infestations; and being yelled at, cursed at, 

or belittled by a client or client’s family. Supervision was rated mostly positively, with the majority of 

respondents noting their supervisors treated them with respect, listened to them, and supported their 

professional development. Respondents reported both positive and negative perceptions of the APS work 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 9

	 	

	 	 	 	 	

	 	 	 	

climate, with workload being perceived negatively. Specifcally, less than half (47%) affrmed that they had 

suffcient resources to do their work, and 37% reported that their workload was reasonable. In addition, 

43% affrmed that employees were protected from health and safety hazards, and 35% reported that their 

work unit recruited those with the right skills. Job satisfaction was rated as moderately high overall, but 

respondents also indicated high burnout risk (22.7%) and risk for secondary traumatic stress (24.6%) 

and low compassion satisfaction (19.9%). The authors state that the fndings highlight the importance of 

building a positive and supportive work environment for APS workers and note that results can help inform 

management strategies for the prevention of burnout among APS workers. 

1L. RESPONDING DURING COMMUNITY EMERGENCIES 

No new supporting research identifed. 

1M. COMMUNITY OUTREACH AND ENGAGEMENT 

Acierno, Hernandez-Tejada, Anetzberger, Loew, and Muzzy (2017) conducted an 8-year follow-up of the 

National Elder Mistreatment Study (NEMS) to specify risk ratios for negative outcomes of elder abuse, 

including Diagnostic and Statistical Manual of Mental Disorders (DSM-5)-defned depression, generalized 

anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and self-reported poor health. Data were 

obtained from 183 NEMS Wave I elder abuse victims and 591 nonvictims. In bivariate analyses, elder 

mistreatment 8 years earlier increased risk of negative outcomes (risk of depression, GAD, PTSD, and selfreported poor health) by 200–700%. However, multivariate analyses revealed that current social support 

was highly protective against most negative outcomes (excepting PTSD) and even appeared to nullify 

effects of mistreatment on GAD and self-reported poor health. The most powerfully consistent predictor 

of current psychopathology and health complaints was not elder mistreatment. Rather, low social support 

consistently predicted negative outcomes. Conversely, high social support diminished risk of depression, 

generalized anxiety, and poor health associated with mistreatment. Thus, when social support from family 

or friends is unavailable or defcient, policy should direct services to compensate or supplement this 

factor. The fndings echoed original NEMS conclusions with respect to the role of social support on risk 

of mistreatment: “The centrality of social support to the health and well-being of older adults is the core 

fnding of this study.” 

Susman, Lees, and Fulmer (2015) examined APS caseworkers’ perceptions of repeated referrals and 

recidivism to APS. Focus groups were conducted with 17 APS caseworkers from the Central Massachusetts 

APS program. Thematic analysis of the focus group transcripts yielded four overarching themes: poor 

communication between referral sources and APS, APS caseworkers as gatekeepers, self-determination, 

and changes in health conditions and family dynamics. Caseworkers discussed diffculties getting the 

information they needed. These diffculties were noted to be due to challenges in communicating with and 

reaching the original referral source (e.g., nurses, emergency medical technicians, banks, families, doctor’s 

offces, hospitals, visiting nurse associations, home care services); to lack of appreciation regarding their 

knowledge and expertise; and to APS being characterized as threat. Caseworkers discussed concerns 

regarding the policy that cases are to be closed after 6 months if an intervention is not actively being 

pursued. They suggested that this may be a reason for clients coming back, as a way to “check in,” noting 

that perpetrators may “be good” until the case has been closed. Since caseworkers must frst receive 

permission from the older adult to begin investigating a case, the caseworker may not be able to intervene 

even when mistreatment is suspected. In terms of changes in referral patterns over the past 5–10 years, 

caseworkers noted that older adults referred more recently were younger than in prior years (in their 60s), 

were more often suffering from signifcant substance abuse or mental health problems, and may be caring 

for their own children with similar problems. This increased complexity in family dynamics was seen as 
10 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	

	 	

	 	 	 	 	

	 	

	 	 	 	 	

	 	 	 	

	 	 	 	 	 	

making it diffcult for older adults to move out of potentially harmful living situations. The authors conclude 

that the identifed themes for recidivism appear amenable to educational interventions for professionals, 

families, and communities in order to reduce repeated visits for services. 

1N. PARTICIPATION IN RESEARCH 

No new supporting research identifed. 

2. TIME FRAMES 

2A. RESPONDING TO THE REPORT/INITIATING THE INVESTIGATION 

No new supporting research identifed. 

2B. COMPLETING THE INVESTIGATION 

No new supporting research identifed. 

2C. CLOSING THE CASE 

Mariam, McClure, Robinson, and Yang (2015) assessed the effectiveness of the Eliciting Change in At-Risk 

Elders (ECARE) elder abuse intervention and prevention program, for building alliances between elders 

with suspected abuse and trained outreach specialists and for helping elders overcome ambivalence 

regarding making diffcult life changes. In the ECARE program, outreach specialists meet with elders in 

person and use different strategies, including motivational interviewing, to build an alliance and connect 

elders to resources in the community based on their readiness to change, preferences, and needs. For 

this study, 47 elders and seven family caregivers (total N=55) of jeopardized elders received the full 

intervention, consisting of extensive assistance in either multiple areas of need or one major area of need 

(e.g., assistance leaving an abusive relationship), of an average duration of 15 hours and 5 minutes over 

three to 36 meetings across 3 to 18 months (mode = 5). The effectiveness of the ECARE program was 

evaluated by examining pre- to postintervention change in the strength of the working alliance between 

outreach specialist and participant, risk factors for further abuse, and movement along Prochaska and 

DiClemente’s (1983)1

 stages of change regarding the key focus of intervention. Results showed that risk 

factors of elder abuse (i.e., economic and housing, and social and community functioning) decreased 

over the course of the intervention. In addition, nearly three quarters of participants made progress on 

their treatment goal, advancing at least one of the stages of change (precontemplation, contemplation, 

preparation, action, and maintenance). Forty-three percent of elders moved into the stages of action and 

maintenance regarding their goal. The authors note that, for other agencies serving at-risk elders, the 

project’s fndings suggest that a longer-term, relationship-based intervention for entrenched elders who 

are reluctant to receive services may be effective and therefore worth considering. 

3. RECEIVING REPORTS OF MALTREATMENT 

3A. INTAKE 

No new supporting research identifed. 

3B. SCREENING, PRIORITIZING, AND ASSIGNMENT OF SCREENED IN REPORTS 

No new supporting research identifed. 

1 Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of 

change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 11

	 	

	 	 	

	 	 	

	 	 	 	

4. CONDUCTING THE INVESTIGATION 

4A. DETERMINING IF MALTREATMENT HAS OCCURRED 

Beach et al. (2017) developed and assessed short-form measures of four types of elder abuse—fnancial, 

emotional/psychological, physical, and neglect—using data from the Elder Abuse Decision Support 

System (EADSS). The EADSS is a data-driven technology-based information system that informs clinical 

decision-making, with the data informing the substantiation decision. The authors note that even though 

the EADSS questionnaires were shown to be effective at helping APS caseworkers substantiate reports 

of alleged abuse, follow-up interviews with caseworkers in Illinois revealed that the entire battery of 

EADSS abuse measures was too time-consuming to administer, given their caseloads. For this study, the 

author identifed items for four abuse/neglect short forms and then tested the validity and reliability of 

the measures. The fndings showed that the four identifed short-form measures, containing 36 of the 82 

original items, have validity similar to the original long forms. The authors suggest that the short forms can 

be used to standardize and increase effciency of APS investigations and may also offer researchers new 

options for brief elder abuse assessments. 

Brink et al. (2015) conducted a retrospective study examining differences in child sexual abuse (CSA) 

determinations for 1422 children who were assessed by a multidisciplinary team (MDT) and the local child 

protective services (CPS). The authors also examined factors associated with differences in determinations 

by the MDT and CPS. Results showed a moderate agreement between MDT and CPS determinations. Of 

the 997 cases determined by the MDT to have a high likelihood for abuse, 789 (79.1%) were substantiated 

or indicated by CPS. In cases where the MDT determined a low or indeterminate likelihood of abuse (425 

patients), CPS did not substantiate or indicate CSA in 78.8% (335 patients). High likelihood of CSA, as 

determined by the MDT, was strongly associated with an increasing total number of CSA disclosures 

and any disclosure of CSA, regardless of abuse severity. Other factors, such as sex, age, race, and 

socioeconomic status based on insurance type, were not associated with this determination, suggesting 

a nonbiased approach to the MDT determination of CSA. For cases with a high likelihood of CSA as 

determined by the MDT and CPS substantiation or indication, there was also a strong association with 

all risk disclosure categories of CSA. The authors suggest that the results highlight the importance of the 

forensic interview in CPS decisions of CSA and the potential role for child advocacy centers in providing 

trained professionals to conduct a high-quality interview during the initial assessment. 

Conrad, Iris, and Liu (2017) examined the effcacy of the Elder Abuse Decision Support System (EADSS) 

for improving individual assessments by comparing substantiation rates for elder abuse for cases in which 

the EADSS was implemented as an investigation system versus cases in which the standard protocol 

in Illinois was used. The EADSS is a data-driven technology-based information system that informs 

clinical decision-making, with the data informing the substantiation decision. The caseworkers use the 

EADSS assessments to obtain the data via client self-report, from collaterals, or from direct observation. 

EADSS computes scores for all measures and creates a summary report. The EADSS care plan links the 

substantiated types of abuse and specifc indicators identifed to suggestions for relevant interventions 

that could be implemented with the consent of the victim. The standard Illinois abuse, neglect, and 

exploitation (ANE) protocol consists of the following: the caseworker conducts a face-to-face interview with 

the alleged victim to determine the veracity of the allegations made in the intake report; then, based on 

one or more interviews, and in consultation with the supervisor, the caseworker reaches a substantiation 

decision on the allegations and then completes the client assessment form, checking off those indicators 

that relate to the abuse he/she had already substantiated. To examine the effectiveness of the EADSS, the 
12 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	

 

 

 

	 	 	 	

authors conducted a pretest/posttest of substantiation results with six agencies that provide ANE services 

in Illinois. Specifcally, prior-year ANE substantiation rates for participating agencies were compared 

as pretest to rates using the EADSS for 1 year as posttest. Findings showed a signifcant difference in 

substantiation rates for the ANE cases (46.6%) versus the EADSS cases (60.2%). For every type of abuse, 

the EADSS abuse substantiation over allegation rate was signifcantly higher than the rate for the ANE. In 

addition, for cases with multiple types of abuse, substantiation rates were signifcantly higher using the 

EADSS (86.3%) versus the ANE standard protocol (43.3%). The authors highlight that the administration of 

comprehensive, standardized, empirically developed procedures helps to ferret out elder abuse. 

Mosqueda et al. (2016) conducted a formative evaluation to assess and understand the variability in 

elder abuse case fndings in California by interviewing APS workers. In California, each county’s APS 

offce reports detailed data on APS investigations to the state department of social services monthly 

using a document called the SOC 242. Each allegation of abuse or neglect is investigated by an APS 

worker to determine whether it is “confrmed,” “inconclusive,” or “unfounded.” The SOC 242 provides 

defnitions of these terms, but the defnitions are not precise. Results showed that the number of 

completed investigations by each county varied widely and that there was a wide range in the percentage 

of confrmed, inconclusive, and unfounded cases. APS workers noted that the limited defnitions of the 

terms allow for a wide variety of interpretations of their meaning. APS workers also noted that variations 

in individual levels of skill, experience, and training can infuence personal decisions on allegations and 

fndings. Others noted the need for training to improve consistency and accuracy for identifying types 

of allegations. Interviewees who were APS employees with prior experience in child protective services 

(CPS) revealed a bias toward “unfounded” fndings. Some respondents stated that the perceived impact 

on resource allocation infuenced social workers’ conclusions. Since “unfounded” fndings may not warrant 

the allocation of services, workers who identify a need for the elder or family to access services, despite an 

absence of abuse, may be biased toward issuing an inconclusive fnding. Many APS workers also expressed 

that it was sometimes diffcult to make a clear determination of capacity. The authors conclude that 

differing interpretations of defnitions of confrmed, inconclusive, and unfounded case fndings, along with 

differences in worker expertise and practices, are the major contributors to variation in elder abuse data. 

Wilber et al. (2014) examined the effectiveness of a multidisciplinary team (MDT) intervention—the Los 

Angeles County Elder Abuse Forensic Center (Center). The authors used a quasi-experimental design, 

focusing on elder abuse cases involving victims aged 65 or older reviewed at the Center between April 

1, 2007, and December 31, 2009. Center cases (n=287) were compared to a propensity-score-matched 

sample of APS cases. Comparison sample selection included all APS referrals aged 65 and over received 

by Los Angeles County’s APS during the study period (n=33,650), excluding any cases heard at the Center. 

Cases reviewed at the Center were signifcantly more likely to be submitted to the district attorney (22%) 

than the comparison APS cases (3%). The proportion of cases in which the district attorney then fled 

charges did not differ signifcantly (73% for the center cases versus 86% for the APS group), nor did the 

proportion of cases with a successful plea or conviction (92% for the center cases versus 100% for the 

APS group). Cases reviewed at the Center were signifcantly more likely to be referred to the Offce of the 

Public Guardian (30.6%) than usual care APS cases (5.9%). The proportion of referred cases that needed 

conservatorship did not differ signifcantly between the Center (52.9%) and the APS cases (41.7%). 

Recurrence of elder abuse was signifcantly reduced in Center cases, from 42.7% at baseline to 24.6%. By 

contrast, usual care APS cases showed a small but nonsignifcant increase in recurrence, from 16.7% at 

baseline to 20.3%. The authors conclude that the elder abuse forensic center MDT model is an effective 

approach as it signifcantly increased prosecution rates and conservatorships for cognitively impaired older 

adults and reduced the rate at which cases reentered the APS system. 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 13

	 	 	

	 	

	 	 	 	

	 	 	 	 	

	 	 	 	 	

4B. CONDUCTING AN APS CLIENT ASSESSMENT 

Burnett et al. (2018) described the Texas Elder Abuse and Mistreatment Institute Forensic Assessment 

Center Network (TEAM-FACN) program as well as preliminary data from its implementation. The TEAMFACN program uses a Web-based portal and low-cost videophone technology to connect an APS agency 

and its clients to a centralized geriatric and elder mistreatment expert medical team for virtual in-home 

assessments. The technology used to conduct video-assisted assessments, including mental health 

assessments, and telephone-based protective service planning during interdisciplinary team meetings, and 

to provide consultation services. After launching the TEAM-FACN program, referrals increased signifcantly, 

suggesting that the program is effective in increasing access to geriatric and elder mistreatment expert 

assessments for APS cases. In addition, the authors suggest it can serve as a model for fostering state 

protective agencies and medical professional collaborations. The authors highlight that the technology 

makes it easier to gather data, access records, complete evaluations, and transmit reports, facilitating 

timely provision of assessments. In addition, it streamlines communication, makes the process quicker, 

and helps prevent unexpected process delays, such as reports being lost in the mail. The authors note that 

virtual assessments also increase timeliness and effciency by dissolving geographic barriers that limit 

expert availability and increase assessor travel time, and they offer a way to enhance collaborations. 

4C. INVESTIGATIONS IN RESIDENTIAL CARE FACILITIES 

No new supporting research identifed. 

4D. COMPLETION OF INVESTIGATION AND FINDING 

No new supporting research identifed. 

5. SERVICE PLANNING AND SERVICE IMPLEMENTATION 

5A. VOLUNTARY SERVICE IMPLEMENTATION 

Acierno (2018) conducted a 5-year follow-up assessment with a subsample of participants from the 

original National Elder Mistreatment Study (NEMS) to assess health and mental health outcomes and 

likelihood of reporting. The results indicated that the effects of past mistreatment were diminished for 

depression and entirely nullifed for generalize anxiety disorder and self-reported poor health when 

current social support was considered. Specifcally, with the exception of post-traumatic stress disorder 

(PTSD), high social support at Wave II appeared to inoculate older adults against negative effects of 

mistreatment 8 years earlier at Wave I for most outcomes. The results also showed that elder fnancial 

mistreatment perpetrated by family, friends, and acquaintances is far less likely to be reported than the 

same behaviors perpetrated by strangers. Surprisingly, rates of nonreporting of emotional mistreatment 

at the hands of strangers was also about 85–90%. The authors suggest that the failure to report 

emotional mistreatment across perpetrator types, in the context of a willingness to report other forms 

of mistreatment when perpetrated by a stranger, indicates that victims of this form of abuse may not be 

aware that it is a type of illegal behavior. 

Burnes, Rizzo, and Courtney (2014) examined factors associated with favorable elder mistreatment (EM) 

protective service case outcomes using a multisite (Manhattan, Brooklyn, and Queens) random sample 

of 233 case records closed between 2009 and 2011 from the Jewish Association Serving the Aging (JASA) 

Legal/Social Work Elder Abuse Program (LEAP). The outcome was risk alleviation— specifcally, level of 

future risk of mistreatment, measured as a multilevel ordinal variable (low risk of future EM, moderate 

risk of future EM, and EM risk remains high/unchanged). Distribution of cases according to outcome 
14 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	 	

	 	 	 	

level of future risk was as follows: low risk (39.1%), moderate risk (29.2%), and high/unchanged risk 

(31.8%). Victim characteristics were more important than perpetrator characteristics in predicting risk 

alleviation, with female and younger victims having poorer outcomes. While victim characteristics emerged 

as signifcantly associated with mistreatment status at case closure in the whole sample, perpetrator 

characteristics appeared as more important in the differentiated subtype analyses. Clients reporting 

evidence of greater social embeddedness outside of the home had more favorable outcomes. Prior 

involvement with a community resource to resolve EM was associated with a higher likelihood of EM 

risk alleviation, and EM victims with higher levels of participation in activities outside of the home had 

borderline greater odds of risk alleviation. Results also showed that a shared living arrangement with the 

perpetrator elevated the risk of future mistreatment, and that EM cases involving longer-term abusive 

relationships (more than 5 years) had lower odds of risk alleviation. The authors suggest that EM social 

service programs should aim to promote elder participation in supportive community social outlets (e.g., 

senior centers). In addition, the authors note that the fnding highlights the need to identify and intervene 

on EM cases as early as possible in the mistreatment trajectory and the need to develop targeted safety 

planning for clients experiencing different forms of abuse and/or neglect. 

Jackson and Hafemeister (2014) assessed whether and how various case characteristics associated with 

abusive situations differ across four pervasive forms of elder maltreatment. Participants included 71 

APS caseworkers, 55 elder victims of abuse, and 35 third-party persons. The authors found signifcant 

associations between types of maltreatment and multiple case characteristics. Among the characteristics 

unique to pure fnancial exploitation (PFE), its victims were more likely to be victimized by a nonrelative, 

more likely to live alone, and more likely to be unaware they were being abused, and the duration of the 

abuse was shorter in length (32 months) than abuse experienced by victims of physical abuse (PA) and 

hybrid fnancial exploitation (HFE). Someone had tried to intervene in only 37% of the cases, a percentage 

considerably lower than for PA (50%) and HFE (69%) cases, suggesting that the victims and/or other 

individuals were less likely to know when PFE was occurring. The PA victims were more likely to be abused 

by a relative, to be more aware that they were being abused, and to have experienced the abuse for a 

longer period of time than PFE and neglect, with the duration of abuse averaging 152 months. Neglect 

victims were more likely to live with the abusive individual, and the abuse was more likely to involve 

a single incident and last for a relatively shorter period of time (28 months) compared to PA and HFE. 

However, no one had tried to intervene in the past, perhaps refecting the isolation of these victims. HFE 

victims were more likely to be victimized by a relative (100%), more likely to have the abusive individual 

living with them, and relatively likely to be aware that they were being abused; and in all cases the abuse 

occurred multiple times. The authors conclude that the profles and manifestations of elder maltreatment 

differ depending on the type of elder maltreatment involved, and they underscore the importance 

of differentiating among the various types of maltreatment when seeking to better understand this 

maltreatment. In addition, the authors note that the different profles indicate the need for interventions 

tailored to meet the unique characteristics associated with each type of abuse, which may lead to greater 

victim safety. 

Mariam et al. (2015) assessed the effectiveness of the Eliciting Change in At-Risk Elders (ECARE) elder 

abuse intervention and prevention program, for building alliances between elders with suspected abuse 

and trained outreach specialists and for helping elders overcome ambivalence regarding making diffcult 

life changes. In the ECARE program, outreach specialists meet with elders in person and use different 

strategies, including motivational interviewing, to build an alliance and connect elders to resources in 

the community based on their readiness to change, preferences, and needs. For this study, 47 elders and 

seven family caregivers (total N=55) of jeopardized elders received the full intervention, consisting of 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 15

	 	 	 	

	 	 	

extensive assistance in either multiple areas of need or one major area of need (e.g., assistance leaving 

an abusive relationship), of an average duration of 15 hours and 5 minutes over three to 36 meetings 

across 3 to 18 months (mode = 5). The effectiveness of the ECARE program was evaluated by examining 

pre- to postintervention change in the strength of the working alliance between outreach specialist and 

participant, risk factors for further abuse, and movement along Prochaska and DiClemente’s (1983)2 

stages of change regarding the key focus of intervention. Results showed that risk factors of elder abuse 

(i.e., economic and housing, and social and community functioning) decreased over the course of the 

intervention. In addition, nearly three quarters of participants made progress on their treatment goal, 

advancing at least one of the stages of change (precontemplation, contemplation, preparation, action, and 

maintenance). Forty-three percent of elders moved into the stages of action and maintenance regarding 

their goal. The authors note that, for other agencies serving at-risk elders, the project’s fndings suggest 

that a longer-term, relationship-based intervention for entrenched elders who are reluctant to receive 

services may be effective and therefore worth considering. 

Sirey et al. (2015) conducted a pilot study to examine the feasibility of implementing routine screening 

for depression and anxiety into an elder abuse service system; test the acceptability of a mental health 

intervention called Providing Options to Elderly Clients Together (PROTECT) to improve depression and 

elder abuse outcomes; and determine the most acceptable format to deliver mental health services 

within elder abuse practice. Three different delivery strategies were used: mental health and abuse 

services provided by the same counselor (“combined”); mental health and abuse services provided 

by different counselors who shared the client (“shared”); and standard referral (“referral”) to nearby 

mental health services, which was the usual procedure. Participants for this pilot were older adults 

(age ≥ 60) receiving services from the New York City Department for the Aging’s Elderly Crime Victims 

Resource Center (ECVRC). For the screening, ECVRC integrated depression and anxiety screening into 

routine case assessment, during the initial evaluation. Individuals with clinically signifcant depression 

or anxiety were randomized to receive one of the three mental health strategies (combined, shared, 

or referral). The PROTECT intervention included problem-solving psychotherapy, anxiety management 

techniques, and psychoeducation about the impact of depressive and anxious symptoms in general, as 

well as the potential impact of symptoms on taking steps to resolve the mistreatment. Staff screened 315 

individuals, with 34% of clients scoring positive for depression or anxiety. Of those with mental health 

needs, only 15% refused all services. PROTECT was successfully implemented in two different formats 

with collaboration between staff workers. The results suggest that clients are willing to accept an offer 

of additional mental health services at the same time that they are receiving mistreatment resolution 

service. Additionally, the pilot data support the potential for elder abuse service providers to work in 

tandem with mental health clinicians. 

5B. INVOLUNTARY SERVICE IMPLEMENTATION 

Gassoumis et al. (2015) conducted a quasi-experimental study to examine the extent to which the 

elder abuse forensic center (forensic center) model, compared to usual APS care, increases the odds 

of conservatorship as a means to improving the safety of victims of elder fnancial exploitation (using 

propensity score matching). The outcomes for this study were whether APS cases were referred to a 

public guardian (PG) and if clients were conserved. Findings indicate that the forensic center team had 

seven times greater odds of referring cases to the PG. While the proportion of cases referred by the 

2 Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model 

of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. 
16 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	

	 	 	

	 	 	 	 	 	 	

center that resulted in conservatorship was not signifcantly different from the proportion in the usual 

care group, there were signifcantly more conservatorships among cases heard at the forensic center 

due to the higher rate of referral. The authors suggest that the magnitude of the observed effects 

indicates that the forensic center offers an effective pathway in bringing cases to the PG’s attention 

for investigation and conservatorship, thereby increasing conservatorship as a remedy for those who 

require the highest level of protection. 

5C. CLOSING THE CASE 

Burnes, Connolly, Hamilton, and Lachs (2018) piloted the feasibility of implementing an adapted 

goal attainment scaling (GAS) procedure to measure client-centered APS case resolution outcomes. 

GAS allows for clients to set individual goals specifc to their needs and construct of success and then 

facilitates assessment of clients’ attainment of these goals. A standardized summary t-score is generated, 

which allows for comparison across clients. Participants for this pilot included 27 community-dwelling 

elder mistreatment victims, age 60 or above, from six Maine APS (MAPS) sites. The GAS process was 

implemented through a Web-based app, in which goals and scales could be selected from a preexisting/ 

prepopulated menu. Findings suggest that GAS is a feasible measurement strategy to implement in the 

APS context. On average, the overall GAS process, including up-front goal identifcation/discussion, 

goal scale creation, and goal scoring, took just over half an hour with each case. Feedback from APS 

practitioners indicated that this amount of time is reasonable within their overall scope of practice, 

especially since GAS complements existing practice, rather than representing an additional task. The 

adapted GAS application, characterized by a preexisting menu of goals and prepopulated goal scales, was 

a useful approach. Virtually all goals used in the GAS process were extracted from the menu. 

6. TRAINING 

6A. CASE WORKER AND SUPERVISOR MINIMUM EDUCATIONAL REQUIREMENTS 

No new supporting research identifed. 

Supporting research from the 2016 Guidelines 

Daly, Jogerst, Haigh, Leeney, and Dawson (2005) studied state regulatory requirements for elder abuse 

workers’ education to determine the requirements’ relationship with rates of reporting, investigating, and 

substantiating cases. Investigation rates were signifcantly higher when the state required that staff have a 

social work degree, but substantiation ratios were signifcantly lower in these same states. 

Jogerst et al. (2004) studied the impact of various APS system characteristics on reports of abuse, 

investigations, and substantiated elder abuse. Data came from a survey of states. Investigators who 

handled reports of abuse of children and adults had lower investigation and substantiation rates than 

those who handled one or the other type of abuse report. 

6B. CASE WORKER INITIAL AND ONGOING TRAINING 

Du Mont, Kosa, Yang, Solomon, and Macdonald (2017) conducted a Canada-based pilot study to assess 

the effcacy of the Elder Abuse Nurse Examiner Curriculum in improving participants’ self-reported 

knowledge and perceived competence to respond to the care needs of abused older women and men, 

and participants’ satisfaction with the curriculum. Participants were 18 sexual assault nurse examiners 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 17

	 	 	

	 	 	 	 	 	

(SANEs) who were trained in the use of the curriculum and completed pre and post questionnaires, as 

well as a training evaluation survey. Results showed signifcant improvements in self-reported knowledge 

and perceived skills-based competence from pretraining to posttraining for all content domains of the 

curriculum: older adults and abuse, documentation, legislative, and legal issues; interview with the 

older adult, caregiver, and other relevant contacts; assessment; medical and forensic examination; case 

summary, discharge plan, and follow-up care. The posttraining evaluation survey showed satisfaction 

among participants across all components of the curriculum and its delivery, particularly with reference to 

the comprehensiveness of the curriculum and the clarity and appropriateness of the training materials. The 

authors conclude that the pilot highlighted the effectiveness of the Elder Abuse Nurse Examiner Curriculum 

in improving SANEs’ self-reported knowledge of and perceived competence in delivering elder abuse care. 

Mosqueda et al. (2016) conducted a formative evaluation to assess and understand the variability in 

elder abuse case fndings in California by interviewing APS workers. In California, each county’s APS 

offce reports detailed data on APS investigations to the state department of social services monthly 

using a document called the SOC 242. Each allegation of abuse or neglect is investigated by an APS 

worker to determine whether it is “confrmed,” “inconclusive,” or “unfounded.” The SOC 242 provides 

defnitions of these terms, but the defnitions are not precise. Results showed that the number of 

completed investigations by each county varied widely and that there was a wide range in the percentage 

of confrmed, inconclusive, and unfounded cases. APS workers noted that the limited defnitions of the 

terms allow for a wide variety of interpretations of their meaning. APS workers also noted that variations 

in individual levels of skill, experience, and training can infuence personal decisions on allegations and 

fndings. Others noted the need for training to improve consistency and accuracy for identifying types 

of allegations. Interviewees who were APS employees with prior experience in child protective services 

(CPS) revealed a bias toward “unfounded” fndings. Some respondents stated that the perceived impact on 

resource allocation infuenced social workers’ conclusions. Since “unfounded” fndings may not warrant 

the allocation of services, workers who identify a need for the elder or family to access services, despite an 

absence of abuse, may be biased toward issuing an inconclusive fnding. Many APS workers also expressed 

that it was sometimes diffcult to make a clear determination of capacity. The authors conclude that 

differing interpretations of defnitions of confrmed, inconclusive, and unfounded case fndings, along with 

differences in worker expertise and practices, are the major contributors to variation in elder abuse data. 

Pickering, Ridenour, Salaysay, Reyes-Gastelum, and Pierce (2018) developed, implemented, and 

evaluated a virtual-reality-based educational intervention intended to improve elder abuse and neglect 

(EA/N) recognition and reporting among mandatory reporters—specifcally, nurses and social workers 

providing in-home services. The educational intervention consisted of two parts, an introductory 

course and an advanced assessment training in virtual reality. Virtual-reality was used to provide 

experiential learning opportunities for teaching the use of the QualCare Scale. The QualCare Scale is 

a direct observational rating scale for identifying the met and unmet needs of the older adult to make 

conclusions about the quality of family caregiving received and the potential for abuse and neglect. To 

pilot the intervention, 39 individuals completed the introductory course, and 36 individuals participated 

in the virtual-reality-based training. The intervention was evaluated by assessing satisfaction, changes 

in knowledge, and changes in practice. Results showed that participants were satisfed with the content 

and format of the training program. Participants made gains in knowledge in identifcation and had 99% 

accuracy in their mandatory reporting decisions. Importantly, professionals reported making changes in 

their daily practice based on knowledge and skills learned. The authors conclude that the data indicate 

that this interdisciplinary training program is a satisfactory way to learn and to produce changes in 

knowledge and clinical practice. 
18 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

	 	 	

	 	

	 	 	

	 	 	

Storey and Prashad (2018) conducted a Canada-based study to test actual and perceived improvements 

among health professionals attending a lengthy multimethod training program that seeks to improve 

confdence, knowledge, and case management skills, including how to identify, report, and investigate 

cases of suspected abuse, neglect, and self-neglect of vulnerable adults. An online survey was used to 

compare outcomes for vulnerable adult specialists who completed the basic “re:act Adult Protection 

Worker Curriculum” (N=109) to outcomes for vulnerable adult specialists who did not complete the training 

(N=48). Across the seven questions asked about perceived knowledge and competence, completers rated 

themselves as having signifcantly more knowledge and competence than did noncompleters. In addition, 

completers answered signifcantly more multiple-choice questions correctly than did noncompleters. There 

were no improvements in applied knowledge. Completers were separated into three groups based on their 

profession: social worker (n = 66, 61%), nurse (n = 35, 32%), and other professional (n = 8, 7%). Of the 

seven questions posed regarding perceived knowledge and competence, signifcant differences were found 

between groups for six questions, with social workers reporting signifcantly more confdence in their 

knowledge and competence than did nurses. The authors conclude that this curriculum and accompanying 

training materials could be made available online to all health authorities for implementation as 

appropriate to local operational needs. 

Supporting research from the 2016 Guidelines 

Connell-Carrick and Scannapieco (2008) studied the impact of training on APS workers’ perceptions of the 

training and their own skills shortly after their training fnished. The training lasted 3 months and involved 

classroom and feld experience. Staff reported positive experiences with training and gains in knowledge 

and skills. They were most confdent in their ability to assess physical abuse and self-neglect and least 

confdent of assessing sexual abuse and fnancial exploitation. 

Jogerst et al. (2004) studied the impact of various APS system characteristics on reports of abuse, 

investigations, and substantiated elder abuse. Data came from a survey of states. Investigators who 

handle reports of abuse of children and adults had lower investigation and substantiation rates than those 

who handled one or the other type of abuse report. 

6C. SUPERVISOR INITIAL AND ONGOING TRAINING 

Ghesquiere et al. 2018 implemented a cross-sectional, anonymous Web-based and in-person survey of 

321 APS workers and supervisors to assess their responses to APS work environments. Overall, 92.8% of 

respondents reported exposure to at least one hazard in their APS careers, and 71% reported exposure 

to one or more hazards in the past month. Respondents reported an average of 3.42 different hazard 

exposures in the past month, with the most common exposures being dangerously cluttered living spaces; 

garbage or spoiled food; insect infestations; and being yelled at, cursed at, or belittled by a client or 

client’s family. Supervision was rated mostly positively, with the majority of respondents noting their 

supervisors treated them with respect, listened to them, and supported their professional development. 

Respondents reported both positive and negative perceptions of the APS work climate, with workload 

being perceived negatively. Specifcally, less than half (47%) affrmed that they had suffcient resources 

to do their work, and 37% reported that their workload was reasonable. In addition, 43% affrmed that 

employees were protected from health and safety hazards, and 35% reported that their work unit recruited 

those with the right skills. Job satisfaction was rated as moderately higher overall, but respondents also 

indicated high burnout risk (22.7%) and risk for secondary traumatic stress (24.6%) and low compassion 
Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems 19

	 	 	

	 	 	 	 	 	

	 	 	

satisfaction (19.9%). The authors state that the fndings highlight the importance of building a positive 

and supportive work environment for APS workers and note that results can help inform management 

strategies for the prevention of burnout among APS workers. 

7. APS PROGRAM RERFORMANCE3 

Booker, Breaux, Abada, Xia, and Burnett (2018) assessed the satisfaction with APS of 77 communitydwelling adults 65 years and over with substantiated self-neglect. Data were drawn from a 6-month 

double-blind randomized controlled trial that examined whether multidisciplinary medical and social 

work team recommendations coupled with APS usual care was more effective at reducing self-neglect 

behaviors in older adults compared to APS-substantiated elder self-neglect receiving usual care only. 

Participants completed the eight-item client satisfaction questionnaire at the end of the 6-month trial. The 

results from the secondary data analysis showed that overall, the majority (77%) of participants indicated 

being satisfed with the APS experience. The highest proportion of responses indicating satisfaction was 

observed regarding recommending APS to a friend in need (87% of subjects reported satisfaction); coming 

back to APS if seeking help again (84% of subjects reported satisfaction); and satisfaction with the amount 

of help received from APS (83% of subjects reported satisfaction). The question with the lowest proportion 

of participants expressing satisfaction asked about the extent to which APS met their needs (65% of 

subjects reported satisfaction), suggesting that APS may beneft from examining its service areas and 

identifying which specifc areas may require expansion to meet client needs. 

Burnes et al. (2014) examined factors associated with favorable elder mistreatment (EM) protective 

service case outcomes using a multisite (Manhattan, Brooklyn, and Queens) random sample of 233 case 

records closed between 2009 and 2011 from the Jewish Association Serving the Aging (JASA) Legal/Social 

Work Elder Abuse Program (LEAP). The outcome was risk alleviation—specifcally, level of future risk of 

mistreatment, measured as a multilevel ordinal variable (low risk of future EM, moderate risk of future 

EM, and EM risk remains high/unchanged). Distribution of cases according to outcome level of future 

risk was as follows: low risk (39.1%), moderate risk (29.2%), and high/unchanged risk (31.8%). Victim 

characteristics were more important than perpetrator characteristics in predicting risk alleviation, with 

female and younger victims having poorer outcomes. While victim characteristics emerged as signifcantly 

associated with mistreatment status at case closure in the whole sample, perpetrator characteristics 

appeared as more important in the differentiated subtype analyses. Clients reporting evidence of greater 

social embeddedness outside of the home had more favorable outcomes. Prior involvement with a 

community resource to resolve EM was associated with a higher likelihood of EM risk alleviation, and EM 

victims with higher levels of participation in activities outside of the home had borderline greater odds of 

risk alleviation. Results also showed that a shared living arrangement with the perpetrator elevated the 

risk of future mistreatment, and that EM cases involving longer-term abusive relationships (more than 5 

years) had lower odds of risk alleviation. The authors suggest that EM social service programs should aim 

to promote elder participation in supportive community social outlets (e.g., senior centers). In addition, the 

authors note that the fnding highlights the need to identify and intervene on EM cases as early as possible 

in the mistreatment trajectory and the need to develop targeted safety planning for clients experiencing 

different forms of abuse and/or neglect. 

3 This domain was revised into two elements (7A. Managing Program Data and 7B. Evaluating Program Performance) as part 

of the updates. 
20 Appendix 2 | Updated National Voluntary Consensus Guidelines for State Adult Protective Service Systems

Susman et al. (2015) 	 	 	 	examined APS caseworkers’ perceptions of repeated referrals and recidivism to APS. 

Focus groups were conducted with 17 APS caseworkers from the Central Massachusetts APS program. 

Thematic analysis of the focus group transcripts yielded four overarching themes: poor communication 

between referral sources and APS, APS caseworkers as gatekeepers, self-determination and changes in 

health conditions and family dynamics. Caseworkers discussed diffculties getting the information they 

need. These diffculties were noted to be due to challenges in communicating with and reaching the 

original referral source (e.g., nurses, emergency medical technicians, banks, families, doctor’s offces, 

hospitals, visiting nurse associations, home care services); to lack of appreciation regarding their 

knowledge and expertise; and to APS being characterized as threat. Caseworkers discussed concerns 

regarding the policy that cases are to be closed after 6 months if an intervention is not actively being 

pursued. They suggested that this may be a reason for clients coming back, as a way to “check in,” and 

noted that perpetrators may “be good” until the case has been closed. Since caseworkers must frst 

receive permission from the older adult to begin investigating a case, the caseworker may not be able to 

intervene even when mistreatment is suspected. In terms of changes in referral patterns over the past 

5–10 years, caseworkers noted that older adults referred more recently were younger than in prior years 

(in their 60s), were more often suffering from signifcant substance abuse or mental health problems, and 

may be caring for their own children with similar problems. This increased complexity in family dynamics 

was seen as making it diffcult for older adults to move out of potentially harmful living situations. The 

authors conclude that the identifed themes for recidivism appear amenable to educational interventions 

for professionals, families, and communities in order to reduce repeated visits for services. As a signifcant 

limitation to studying mistreatment cases, the authors highlight the lack of longitudinal data. Specifcally, 

the state of Massachusetts is required to expunge APS records from substantiated cases within 7 years, 

making it diffcult to follow cases over a protracted period of time. 

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