Elder Justice: More Federal Coordination and Public Awareness Needed
Released: 2013-07-10T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: As the percentage of older adults in the population increases, the number of older adults at risk of abuse also is growing. At the same time, constraints on public funds may limit assistance to the growing population of older adults in need. GAO was asked to review elder justice program issues. This report addresses: (1) the extent to which there is fragmentation, overlap, or duplication across the federal grant programs that support elder justice; (2) the extent to which federal programs coordinate their efforts and monitor elder justice outcomes; and (3) how state aging agencies, area agencies on aging, and service providers deliver federal elder justice services and what challenges, if any, they face in doing so. GAO reviewed relevant federal laws and regulations, identified federal elder justice programs, surveyed federal officials about program elements, reviewed program documentation, and visited agencies responsible for elder justice in Illinois, Virginia and Arizona. GAO selected states based on the percentage of the elderly in the state population, geographic dispersion, and percentage of the state's Older American Act funds devoted to elder care.

section_title: What GAO Found
paragraphs: In fiscal year 2011, two agencies--the Departments of Health and Human Services (HHS) and Justice (Justice) --separately administered 12 fragmented but minimally overlapping programs that directed funds toward elder justice, with low risk of duplication. Specifically, because more than one federal agency administers these programs, GAO found that these grant programs are fragmented. Further, GAO found that overlap across the 12 programs was minimal because the programs varied with respect to (1) funding mechanisms and recipients, (2) elder abuse victims targeted, (3) service providers, and (4) activities conducted. For example, a few of these programs provided formula grants to all states and most dispersed discretionary grants to a limited number of recipients. Programs that supported victims of elder abuse generally assisted all types of victims, but some also focused on certain subgroups, such as older women. Some programs that assisted service providers also targeted specific subgroups, such as judges and court personnel. In addition, elder justice programs supported a wide range of activities. For example, one HHS program provided public education to help identify and prevent elder abuse, while a Justice program trained law enforcement officers to investigate instances of elder abuse. Considering the variation across funding mechanisms and recipients, the elder abuse victims and service providers targeted by the grants, and the types of activities conducted, overlap across the 12 programs is minimal and the risk of duplication--when two or more agencies or programs are engaged in the same activities or provide the same services to the same beneficiaries--is low.

We have previously reported that coordination is key to ensuring the efficient use of limited resources to address issues that cut across more than one agency. While federal coordination is in development--for example, HHS, Justice, and other agencies recently formed the Elder Justice Coordinating Council--federal agencies have yet to articulate common objectives and outcomes as precursors to future measures for elder justice programs, which would provide a rationale for coordination. Further, few federal programs tracked elder justice outcomes in 2011 or conducted program evaluations to assess effectiveness, making it difficult to determine what impact, if any, many programs have on victims of elder abuse.

Officials representing state aging agencies, area agencies on aging and service providers in the three states GAO visited identified the increased demand for elder justice services in a constrained fiscal environment as a major challenge in meeting the needs of the growing older adult population. Officials also cited the need for greater awareness of elder abuse by the public and training of direct service providers who interact with older adults on a regular basis, to help prevent elder abuse or recognize its symptoms. Five of the nine regional agency officials GAO spoke with said elder justice issues need to be elevated to national attention for the general public by a national public awareness campaign. The Elder Justice Coordinating Council is considering a recommendation to sponsor a national campaign but has not yet done so.

section_title: What GAO Recommends
paragraphs: GAO recommends that HHS take the lead in identifying common objectives and outcomes for the federal elder justice effort and that HHS and Justice develop a national elder justice public awareness campaign. HHS concurred and Justice did not comment.

section_title: Letter
paragraphs: GAO, Elder Justice: Stronger Federal Leadership Could Enhance National Response to  Elder Abuse, GAO-11-208 (Washington, D.C.: March 2, 2011) and Elder Justice: National  Strategy Needed to Effectively Combat Elder Financial Exploitation, GAO-13-110  (Washington, D.C.: Nov. 15, 2012). providers deliver federal elder justice services and what challenges, if  any, they face in doing so.

GAO, 2012 Annual Report: Opportunities to Reduce Duplication, Overlap and  Fragmentation, Achieve Savings, and Enhance Revenue, GAO-12-342SP (Washington,  D.C.: Feb. 28, 2012).

While there is no standard definition for what constitutes a federal program, we defined  “program” as an organized set of activities supported by a congressional appropriation,  allocation, or authorization.  This can include grants, initiatives, centers, loans, funds, and  other types of assistance. Further, we defined a program as a single program even when  its funds were allocated to other programs as well, such as a block grant. information. The survey collected information on key program elements,  including objectives, activities, target populations, outcome measures,  and obligations during fiscal year 2011. The survey response rate was  100 percent. The survey also allowed us to confirm, exclude, and add  programs based on consultations with agency officials. As a result of our  analysis of the survey data and follow-up contact with agency officials, we  identified 12 programs that met one of the first two selection criteria and  funded elder justice activities in fiscal year 2011. We analyzed whether  similarities and differences in key program elements indicated potential  fragmentation, overlap, or duplication, and whether program officials  monitored program outcomes. Appendix I provides a detailed description  of our methodology for the survey and its limitations, as well as its scope.

To determine the extent to which federal programs coordinate their efforts  and monitor elder justice outcomes, our survey collected information on  federal elder justice programs’ coordination, monitoring, and program  evaluation. We conducted written follow-up with program officials about  their efforts, reviewed their planning documents, and assessed this  information to identify elder justice programs’ monitoring and coordination  efforts.

To determine how state aging agencies, area agencies on aging and  service providers deliver federal elder justice services and what  challenges, if any, they face in doing so, we conducted site visits to  Arizona, Illinois, and Virginia. We selected these states because a  relatively high percentage of the state population is over 60 years of age;  geographic dispersion; and a relatively high percentage of Older  Americans Act of 1965 funding in the state’s budget is devoted to elder  care.4 In each state, we interviewed staff from the state aging agency,  and three area aging agencies, and in one state, officials from two local  service providers, about challenges in delivering elder justice services.  We also interviewed experts in the field of aging and elder abuse  including representatives of the American Bar Association-Commission  on Law and Aging, the National Health Policy Forum, the National  Association of States United for Aging and Disabilities, and the Woodrow  Wilson International Center for Scholars.  Findings from these site visits  are not generalizable to all aging agencies or service providers, but  provide important insights.

Pub. L. No. 89-73, 79 Stat. 218 (codified as amended at 42 U.S.C. §§ 3001-3058ff).
subsections: section_title: Background
paragraphs: Elder justice can be defined as efforts to prevent, identify, and respond to  elder abuse. The following are examples of the types of objectives federal  elder justice programs may include:

Preventing and identifying elder abuse, such as conducting outreach  and public education and investigating allegations of elder abuse.

Responding to elder abuse, such as providing counseling, prosecuting  elder abuse cases, advocating on behalf of nursing home residents,  and offering legal assistance.

Providing training and technical assistance related to elder abuse for  individuals and agencies.

Conducting research related to elder abuse issues, such as the  development of information and data systems and identifying the  incidence.
subsections: section_title: Federal Elder Justice Program Structure
paragraphs: Federal elder justice programs are administered and funded through a  complex intergovernmental structure. The Older Americans Act of 1965  (OAA) established the Administration on Aging (AoA) within the  Department of Health and Human Services (HHS) as the chief federal  advocate for older Americans5 and assigned responsibility for elder abuse  prevention to the AoA. In April 2012, HHS established the Administration  for Community Living (ACL), which brought together the AoA, the Office  on Disability and the Administration on Developmental Disabilities to  better align the federal programs that address the community living  service and support needs of both the aging and disability populations,  among other things.

42 U.S.C. § 3012(a)(1).

Elder justice programs funded by HHS are implemented through the  aging services network.6  Authorized by the OAA, the aging services  network was developed to help people age 60 and over maintain  maximum independence in their homes and communities and to promote  a continuum of care for vulnerable older adults. The aging services  network is now made up of 56 state aging agencies, 629 area agencies  on aging (AAAs), and almost 20,000 service provider organizations, many  of which rely on volunteers, that deliver services to older adults.7 Further,  the OAA authorizes grants administered by the AoA, within ACL, to fund  initiatives for those 60 years of age and older throughout the aging  services network, including social services such as home-delivered  meals, legal assistance, employment programs, research and community  development projects, and training for professionals in the field of aging.8  Elder justice programs supported by the Department of Justice (Justice)  also are delivered through the aging services network as well as through  other state agencies, local social service and government agencies, and  tribal government agencies.

The OAA uses the term “aging network” (42 U.S.C. § 3002(5)) but we found the more  descriptive term “aging services network” in widespread use.

Area agencies on aging are sub-state organizations that can encompass one or more  local governmental jurisdictions, such as cities and counties.   42 U.S.C. § 3024.  42 U.S.C. § 3025(a)(2)(A). regional planning and development agencies.10 The rest are located in  colleges, community action agencies and other organizations.

National Health Policy Forum Background Paper No. 83: The Aging Services Network:  Serving a Vulnerable and Growing Elderly Population in Tough Economic Times,  December 13, 2011.  42 U.S.C. §§ 1397-1397k-3.

Pub. L. No.111-148, tit. VI, subtit. H, §§ 6701-6703, 124 Stat. 119, 782-804 (2010)  (codified at 42 U.S.C. §§ 1397j-1397m-5).

Pub. L. No. 109-432, § 405, 120 Stat. 2922, 3053.

Pub. L. No. 106-386, sec.1209(a), § 40802, 114 Stat. 1464, 1508 (codified at 42 U.S.C.  § 14041a).

Pub. L. No. 103-322, tit. IV, 108 Stat. 1796, 1902-1955.

Pub. L. No. 109-162, § 205, 119 Stat. 2960, 3002 (codified as amended at 42 U.S.C. §  14041a).

Violence Against Women Reauthorization Act of 2013, Pub. L. No. 113-4, 127 Stat. 54.

See appendix II, table 9. financial abuse is explicitly included in the mission of the CFPB’s recently  established Office of Financial Protection for Older Americans.19 Figure 1  shows the federal, state, regional and local service agencies that support  and deliver elder justice efforts.

12 U.S.C. § 5493(g)(3).

Multiservice organizations are organizations that deliver more than one type of public  benefit program, such as congregate meals, Supplemental Nutrition Assistance Program  cards, and legal assistance.  State attorneys general may also play a consumer protection role.   Justice also plays a consumer protection role.  Social service agencies include domestic violence and sexual assault victim services  providers.

section_title: Elder Justice Funding
paragraphs: HHS and Justice fund elder justice programs through formula grants and  discretionary grants to agencies as well as tribal and non-profit  organizations in each state. For programs that deliver funds through  grants, the state agencies submit applications or agree to meet certain  requirements with information provided by regional or local agencies,  which may provide the services themselves or contract with independent  providers to deliver the services. Some HHS and Justice programs are  funded through discretionary grants, which may be awarded directly to  any eligible applicant that meets eligibility criteria. Eligible applicants for  HHS and Justice elder justice discretionary grant programs may include  area agencies on aging, multi-service organizations, district attorneys’  offices, legal assistance groups and postsecondary institutions. Figure 2  illustrates the flow of funding for elder justice programs from HHS and  Justice to several types of grant recipients.

section_title: Federal Elder Justice Programs Are Fragmented but Minimally Overlapping, Reducing the Risk for Duplication
subsections: section_title: Federal Elder Justice Programs Are Administered by Multiple Agencies
paragraphs: In fiscal year 2011, HHS and Justice administered 12 programs that  directed federal funds toward elder justice programs.  Seven of these  programs directed all funds toward elder justice in fiscal year 2011; the  other five directed some of their funds toward elder justice but supported  activities for other purposes, as well. Table 1 lists the 12 programs that  directed funds toward elder justice. The fiscal year 2011 obligations  reported in table 1 include federal funds only.

Because more than one agency is involved in this same broad area of  national interest, and the agencies have just begun to coordinate their  activities, these programs are fragmented. However, the administration  has begun to take steps to enhance coordination which, as we previously  reported, can help address some of the problems that arise from a  fragmented array of programs supporting the same national interest.21    In addition, we identified 34 other federal programs that supported elder  justice indirectly—by providing federal funds for elder justice as an  allowable activity(see fig. 3). Because elder justice was an allowable  activity in these 34 programs, grant recipients determined whether elder  justice activities would be conducted in a given fiscal year.22 As a result,  federal program managers could not tell us which elder justice activities to  compare for that year, to determine if overlap or duplication occurred, for  those 34 grant programs.

GAO, Results-Oriented Government: Practices that Can Help Enhance and Sustain  Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005),  and GAO-12-342SP.

See appendix II for more information on 34 programs.

section_title: Overlap and Duplication are Minimal in Federal Elder Justice Effort
paragraphs: The 12 programs supported elder justice activities through a variety of  federal funding mechanisms. Ten of the programs supported the federal  elder justice effort through grants to a variety of grantees such as states,  localities, universities, and other grantees, while the remaining two  programs—HHS’ Interpersonal Violence within Families and Among  Acquaintances Prevention program and Justice’s Elder Justice and  Nursing Home Initiative—did not award grants but administered contracts  and interagency agreements. Because few of these programs provided  formula grants to all states and most dispersed discretionary grants to  limited number of recipients of several types, there is minimal overlap in  this area.

Specifically, 3 of the 10 grant programs provided a guaranteed base of  funding through formula grants to all states; however, each of these  programs awarded grants to state agencies for different purposes and the  state agency recipients of the HHS grants differed from the recipients of  the Justice grant.23 One HHS program awarded formula grants to state  aging agencies to fund elder justice prevention and awareness activities  and the other program funded assistance to residents of long term care  facilities. The Justice program awarded formula grants to state criminal  justice agencies to fund elder justice activities as well as other law  enforcement and prosecution strategies. Moreover, 7 of the 10 elder  justice grant programs required recipients to compete for funding by  awarding discretionary grants to a limited number of grant recipients.  Three of these discretionary grants provided funding to direct service  providers, such as local organizations serving domestic and sexual  assault victims, local governments, or courts. The remaining four  discretionary grants provided funding to a nonprofit organization and a  limited number of postsecondary institutions to operate resource centers  for state and local governments or to conduct research related to elder  mistreatment.

Federal elder justice programs also provided support for a variety of types  of victims and potential victims of elder abuse.  Nine of the 12 programs  provided services to victims and potential victims of elder abuse: 5  provided assistance to all types of victims and 4 focused on key  subgroups of victims, further reducing the potential for overlap. For  example, 1 of the 4 programs served older female victims, another  targeted victims in long-term care facilities, and still another served  victims in tribal communities. Table 2 displays the types of victims  targeted by the federal elder justice programs we identified.

The three formula grant programs were HHS’ Prevention of Elder Abuse, Neglect, and  Exploitation program (42 U.S.C. § 3058), HHS’ Long-Term Care (LTC) Ombudsman  Program (42 U.S.C. § 3058g), and Justice’s Services, Training, Officer, and Prosecutors  (STOP) Violence Against Women Formula Grant Program (42 U.S.C. § 3796gg-1).

These programs did not directly serve victims or potential victims directly, rather they engaged in  research on elder abuse in general.

Moreover, a variety of service providers—organizations that deliver  services at the state and local level—were supported by the 12 elder  justice programs. In 2011, 8 programs targeted specific subgroups of  service providers while 4 programs did not target subgroups of service  providers. Even some of the 4 programs that provided support to all types  of service providers specialized to some degree. For example, one  program supported outreach focused on tribal elders while another  focused on elder mistreatment research (see table 3).

In addition to serving a range of elder abuse victims and service  providers, the 12 programs we identified varied with respect to the  activities they supported, with minimal overlap in some activities (see  table 4). For example, 4 programs provided victim assistance services.  Two programs provided support for conducting investigations of  complaints concerning different members of the older adult community,  including residents of long-term care facilities and female victims in the  community.

Three broad categories of activity—education, outreach, and information  dissemination; training and technical assistance to service providers; and  promoting state and local coordination—were supported by most of the  12 programs we identified. While some of these activities—education and  outreach training for service providers, and state and local coordination— appear to overlap, these activities were not necessarily providing similar  services to similar populations. For example, one program supported  public education and outreach to potential victims to promote financial  literacy among older adults and prevent financial exploitation. Another  program trained law enforcement officers to recognize and investigate  instances of abuse and trained staff in victim services organizations and  governmental agencies to understand the role each plays in addressing  elder abuse in the community. A third program promoted local  coordination among human services organizations, law enforcement, and  community development programs just within tribal communities. Further,  some of the grant programs identify several allowable activities grantees  may conduct using program funds, only a few of which may be elder  justice-related, but do not require grantees to conduct all of them.  In one  case, the sponsoring agency does not track which elder justice projects  are funded. For example, in describing the department’s grant  administration practices for the STOP Violence program, a Justice official  explained that state agencies maintain records of the elder justice  projects they fund but Justice does not. Thus, the number of grantees that  conduct elder justice activities is not known by Justice.

When considering, collectively, the variation in the types of funding  mechanisms and grant recipients, the elder abuse victims and service  providers targeted by the grants, and the types of activities conducted, we  found overlap across the 12 programs was minimal.  In addition, the  potentially overlapping activities have been cited as being in need of  greater federal emphasis, as we will discuss later in this report. For  example, public awareness and training for professionals working with  elder abuse victims were two of the areas identified by some of the state  and local officials we interviewed as those in which increased federal  support would be beneficial. Also, previously discussed, we have  recommended that coordination among state and local organizations has  helped mitigate the effects of increasingly limited resources.

Moreover, the key differences noted above, in conjunction with low levels  of funding, reduce the risk that two or more area agencies on aging or  local service providers would be providing the same services to the same  beneficiaries—that is, that they are providing duplicative services.  With  respect to low funding levels, by the time federal elder justice funds are  obligated to grantees nationwide, the amount of funds available to any  individual service provider is likely to be low. State officials in all three  states we visited said that HHS is the primary federal funding source for  their elder justice activities. Under two HHS programs, the Prevention of  Elder Abuse, Neglect, and Exploitation program and the Long-Term Care  (LTC) Ombudsman Program, the federal government distributes funds to  state aging agencies, which then allocate funds to area agencies on  aging or local service providers. For example, in fiscal year 2011, of the  $5,033,000 total obligations for the Prevention of Elder Abuse, Neglect  and Exploitation program, which directs all funds toward elder justice,  HHS provided $197,380 to Illinois’ state aging agency. The allocation to  one of the state’s 13 area agencies on aging was $14,488, which it then  distributed to numerous other local service providers working directly with  older adults, such as county human service agencies. In Virginia, HHS  provided $118,040 to the state aging agency from the Prevention of Elder  Abuse, Neglect and Exploitation program fiscal year 2011 obligations.  According to officials at one of Virginia’s 25 area agencies on aging, the  allocation to that agency was $3,027 for that fiscal year.

section_title: Federal Coordination of Elder Justice Activities Is in Development, but Monitoring Is Limited
subsections: section_title: Federal Coordination of Elder Justice Activities Is in Development
paragraphs: GAO, Results-Oriented Government: Practices that Can Help Enhance and Sustain  Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005).

GAO-06-15. identified practices that can enhance coordination efforts, such as  defining and articulating a common federal outcome or purpose agencies  are seeking to achieve, consistent with their respective goals and  missions. Developing a common federal outcome establishes a rationale  for agencies to collaborate that helps overcome significant differences in  agencies’ missions, cultures, and established ways of doing business that  may lead them to work at cross purposes.

HHS and Justice are involved in developing efforts to coordinate their  elder justice activities. Most recently, the Elder Justice Coordinating  Council (Council) was established under the Elder Justice Act of 2009  (EJA) to address cross-agency coordination of activities relating to elder  abuse, neglect, and exploitation.26  According to the EJA, the Council  should include members representing HHS, Justice, and other federal  entities with responsibilities or programs related to elder abuse. The  Council held an inaugural meeting in October 2012, where it identified  four issue areas for action—financial exploitation, public policy and  awareness, enhancing response, and advancing research—and collected  white papers from issue area experts. The white papers included  recommendations for improving and advancing the field of elder justice.  The Council is required to make recommendations to the Secretary of  HHS for the coordination of elder justice activities by relevant federal  agencies and report to Congress on accomplishments, challenges, and  recommendations for legislative action every 2 years.

The Council met again in May 2013 to consider next steps. The Elder  Justice Interagency Working Group (Working Group), an informal group  designed to bring together federal officials responsible for carrying out  elder justice activities, presented recommendations distilled from the  white papers.  The working group’s recommendations included such  actions as launching an elder justice web site, developing elder justice  forensic centers, a national APS data system, a national public  awareness campaign, and strategies for combating financial exploitation  in collaboration with industry.

42 U.S.C. § 1397k.

The EJA also established an Advisory Board on Elder Abuse, Neglect,  and Exploitation (Advisory Board), which has a mission, distinct from the  Council, of developing innovative approaches to improving the quality of  long-term care, including preventing abuse, neglect, and exploitation.28  The Advisory Board is tasked with creating short- and long-term strategic  plans for the development of the elder justice field and making  recommendations to the Council. Unlike the Council, which is comprised  of federal agency officials who administer elder justice programs, the  Advisory Board will be made up of appointed members from the general  public with experience and expertise in elder abuse, neglect, and  exploitation prevention, detection, treatment, intervention, and  prosecution. Progress so far has included a solicitation for nominations  for members, issued by HHS on July14, 2010.29  In addition, HHS and Justice officials from 10 of the 12 elder justice  programs we identified said they were involved in informal or ad hoc  coordination efforts with other federal programs. For example, officials  representing 8 programs reported participating in joint program planning  and implementation, such as assisting in the review of grant solicitations,  collecting and sharing materials to support elder mistreatment  prosecutions, and supporting training initiatives. Other coordination efforts  program officials reported include participating in joint information  sessions—such as elder abuse awareness events—jointly funding a  training initiative, and sharing data and information about trends,  prevention efforts, and responses to abuse, with other agencies or  programs.

section_title: Federal Programs Did Not Track Elder Justice Outcomes in 2011
paragraphs: While federal agencies have taken steps to better coordinate their efforts,  less progress has been made in articulating and tracking common goals  for federal elder justice activities. Program officials reported that 4 of the  12 federal programs we identified tracked elder justice outcomes in 2011  and one had conducted a program evaluation to determine effectiveness.

42 U.S.C.§1397k-1.

Establishment of the Advisory Board on Elder Abuse, Neglect, and Exploitation,75 Fed.  Reg. 40,838 (July 14, 2010).

1993 (GPRA)30—as recently enhanced by the GPRA Modernization Act  of 201031—can also serve as leading practices for planning at lower  organizational levels, such as individual programs or initiatives.32 GPRA  provides federal agencies with a way to focus on results and improve  agency performance by, among other things, developing strategic plans.  Examples of strategic plan components include a mission statement;  general goals and objectives, including outcome-oriented goals; and a  description of how the goals and objectives are to be achieved.

While HHS and Justice, the two agencies that oversee the 12 federal  elder justice programs we identified, each have defined broad strategic  goals and objectives at the department level that may impact elder justice  (see table 5), and ACL has identified a strategic goal related to its elder  justice responsibilities, the departments have not formally defined  common goals for addressing concerns of elder abuse, neglect, and  exploitation.

Pub. L. No. 103-62, § 4(b), 107 Stat. 285, 287 (codified as amended at 31 U.S.C. §  1115(a)(1)).

Pub. L. No. 111-352, § 3, 124 Stat. 3866, 3867-68 (2011) (codified at 31 U.S.C. §  1115(a)(1)).

GAO, Veteran-Owned Small Businesses: Planning and Data System for VA’s  Verification Program Need Improvement, GAO-13-95 (Washington, D.C.: January 14,  2013).

Strategic goal 3: Advance the health, safety,  and well-being of the American people.

Objective 3.C: Improve the accessibility  and quality of supportive services for  people with disabilities and older adults.

Administration for Community  Living strategic goal 4: Ensure  the rights of older people and  prevent their abuse, neglect,  and exploitation.

Strategic goal 2: Prevent crime, protect the  rights of the American people, and enforce  federal law.

Objective 2.2: Prevent and intervene in  crimes against vulnerable populations;  uphold the rights of, and improve  services to, America's crime victims.

Objective 3.1: Promote and strengthen  relationships and strategies for the  administration of justice with state, local,  tribal, and international law  enforcement.

Justice’s fiscal year 2012 performance and accountability report also cites priority goals, intended to  represent critical elements of the agency’s strategic plan, which includes a priority goal to protect  those most in need of help, such as vulnerable populations including the elderly.

Among the 12 federal programs, we determined that 4 tracked outcomes  for potential victims of elder justice in 2011.

HHS’s LTC Ombudsman Program reported the number of complaints  made by residents in long-term care facilities, which include those  related to elder abuse, neglect, or exploitation, that were resolved to  the satisfaction of the resident.

HHS’s NIA Developmental Research on Elder Mistreatment program  tracked the number of scientific publications resulting from NIA  funding as a measure of the program’s performance in meeting its  intended purpose of supporting research on elder mistreatment.

Justice’s Tribal Elder Outreach Program33 monitored outcomes  related to service delivery for individual grant recipients, though these  data were not aggregated for the full program. Outcomes individual  grantees reported included the number of tribal victims served as a  result of outreach efforts, according to Justice officials.  Justice’s Abuse in Later Life Program monitored outcomes at the  grantee level. Outcomes the program tracked included the number of  professionals trained to respond to domestic violence and sexual  assault as well as the number of individuals receiving services.

For three of the eight programs that did not track elder justice outcomes  in 2011, officials said they plan to do so in the future. For example,  officials from two of the programs that directed all funds toward elder  justice said they plan to develop and monitor outcomes. For example,  HHS’s National APS Resource Center has identified program outputs,  that will inform the development of outcome measures, such as a  literature review of evidence-based APS programs and a related webinar,  which will aim to improve the knowledge-base of participants. Similarly,  the National Center on Elder Abuse,35 also funded by HHS, has identified  outcomes such as elder abuse awareness and the extent to which  research findings are integrated into training and practice.

Similarly, formal evaluation of federal elder justice programs is limited.  As  we have previously reported, researchers designing formal evaluations  for other programs, including one welfare program, have found that they  had to fit the evaluation design to available time and resources, even  when an evaluation is planned for the state rather than the federal level.36   For example, in some cases, conducting an evaluation for an entire state  may be determined to be so expensive that data collection has to be  limited to a portion of the state. Thus, individual program efforts may not  always be feasible within the resources of many elder justice programs.   Nevertheless, one program, HHS’ NIA research program, held a  conference to evaluate the progress of research supported by grants  42 U.S.C. § 10603(c)(1).

42 U.S.C. § 3012(d).

GAO, Designing Evaluations: 2012 Revision, GAO-12-208G (Washington, D.C.: Jan.  31, 2012); and Welfare Reform: Data Available to Assess TANF’s Progress, GAO-01-298  (Washington, D.C.: Feb. 28, 2001). awarded to research elder justice issues in 2010. Three of the 11  remaining programs also indicated they plan to conduct evaluations in the  future once more work has been completed or if funding becomes  available.  Officials from the other 8 programs reported they have not  recently conducted nor do they plan to conduct a formal evaluation that  includes an assessment of elder justice activities. Program officials cited  several factors that limit their ability to formally evaluate their programs,  including variability of program activities and scope year by year,  insufficient data due to a short period of implementation for newer  programs, and limited resources, including funding devoted to and  expertise in program evaluation.

Given the costs associated with evaluating individual programs,  developing common objectives and outcomes for HHS and Justice elder  justice programs could be a first step in assessing the federal effort. As  noted, coordination of these programs is just under way and HHS and  Justice have not developed common objectives for the elder justice effort  nor have they defined a set of common outcomes, which are necessary  precursors to future performance measures, that could be used to  evaluate the federal effort as a whole. Without progress on these fronts,  the federal government cannot assess the effectiveness of its effort nor  the efficient use of resources devoted to elder justice activities.

section_title: Challenges Persist in Serving Older Adults and Stakeholders Identified a Need for Additional Training and Awareness
paragraphs: Officials from the state aging agencies, area agencies on aging, and  service providers we interviewed identified the increased demand for  services in a constrained fiscal environment as a major challenge in  meeting the needs of the growing older adult population. State aging  agency, area agency on aging, and service provider officials also cited  the need for greater awareness of elder abuse, by both the public and  individuals who interact with older adults, to help prevent elder abuse or  recognize its symptoms. Further, officials in all of the state aging agencies  we contacted told us that elder abuse cases are increasing, especially  financial exploitation cases. For example, one state official we spoke with  said that, as they gave greater emphasis to such cases, they found that  elder justice cases involving financial exploitation, in particular, take  longer to investigate, use financial records that are difficult to obtain, and  are often harder to prove than physical or emotional abuse.

Elder justice activities are a small but important component of the broad  range of services area agencies on aging (AAA) provided in the states we  visited. Among these elder justice services were basic legal services to  older adults, such as assisting with setting up wills, power of attorney, or  advance directives, which can help deter financial exploitation. AAAs we  visited also coordinated a number of other types of elder justice services.  For example, an Arizona AAA administers a program funded through a  Justice Victims of Crime Act grant to provide emergency housing for  abused older adults. The same AAA uses HHS Title VII of the OAA  funding for a Boys and Girls Club program to teach young people about  respecting older adults. In Illinois, a Justice STOP grant helped create the  Elder Law and Miscellaneous Remedies Division of the Circuit Court of  Cook County which handles elder abuse cases and other instances  where the victim is an older adult.

Officials representing all of the nine AAAs and nine of the local providers  we interviewed also helped raise awareness of elder abuse through  education and training programs both for the public in general and for  those members of the community who regularly interact directly with older  adults. For example, in Virginia, a local service provider received a  Justice grant to train criminal justice professional service providers,  victims, witnesses, and anyone likely to come in contact with elders. Such  individuals may not be aware of the different ways abuse can present  itself in the older adult population, and other AAA officials said that  education and training for these direct service providers could help them  identify it and respond appropriately. The Virginia provider saw its  program as helpful in determining how to address an abused older adult’s  problems. In our view, in the absence of this awareness, incidents of  elder abuse may go unreported or unaddressed.

For the most part, APS agencies in Arizona and Virginia worked with  AAAs to identify and respond to incidents of elder abuse. Although the  administrative structure of the AAAs and APS agencies can vary from  state to state, the basic AAA services can help bolster an older adult’s  independence after an elder abuse incident. Depending on the division of  responsibility for elder justice services in the state, AAAs may refer  reports of elder abuse to the state’s APS program in their area. For  example, in Arizona and Virginia, the AAAs turn any allegations of elder  abuse over to the state APS program upon learning about it. However, in  Illinois, the state contracts with service providers to conduct the entire  investigation and disposition of the elder abuse cases. Once an  investigation has been conducted and service needs identified, AAAs  may be involved in connecting elder abuse victims to services.

Despite their efforts to raise awareness of elder abuse in their  communities, officials at five AAAs and four local service providers told us  that more public awareness and training was needed. Moreover, officials  from state aging agencies in two of the three states we visited said that  the federal government should further emphasize the need for training  law enforcement officers and other officials in identifying elder abuse for  when they come in contact with older adults in need. An AAA official in  one of these states said that training resources should also be directed to  healthcare officials, because they are in a position to identify signs of  elder abuse.

In prior work on elder financial exploitation, experts and federal, state,  and local officials focusing on this form of elder abuse told us that older  adults need more information about what constitutes financial exploitation  to know how to avoid it. That prior study found that each of the seven  federal agencies reviewed independently produces and disseminates  public information on elder financial exploitation that is tailored to its own  mission, and  worked together at times to increase public awareness. For  example, each year, the FTC and the Postal Inspection Service  collaborate on community presentations during National Consumer  Protection Week. However, although the Older Americans Act calls for a  coordinated federal elder justice system, which includes educating the  public, the seven agencies reviewed in that prior study did not undertake  these activities as part of a broader coordinated approach.37 In other work  on public program effectiveness, we have concluded that agencies can  use limited funding more efficiently by coordinating their activities and can  strengthen their collaboration by establishing joint strategies.38  Of the nine AAA officials we spoke with for this review, five said that there  is a need for a strategic, national public awareness campaign on elder  justice, not limited to financial exploitation. Officials at three of these  AAAs suggested that the federal government sponsor a national  campaign to raise awareness that would include broadly dispersed public  education announcements on the prevalence and types of elder abuse  and helpful resources for those in need. The campaign would help service  providers and care givers who interact with older adults or observe their  behavior recognize the signs of elder abuse and report it.

GAO, Elder Justice: National Strategy Needed to Effectively Combat Financial  Exploitation, GAO-13-110 (Washington, D.C.: Nov. 15, 2012).

GAO-06-15.

During its meeting in May 2013 to consider next steps, the Elder Justice  Coordinating Council moved closer to developing a coordinated federal  effort to prevent and respond to elder abuse. One of the actions  recommended by the Council’s Federal Interagency Working Group was  the development of a national public awareness campaign. However, the  Council is currently considering this recommendation and has not yet  taken a final decision. Our work for this study indicates that until a broad- based public awareness campaign is established, many incidents of elder  abuse may be unreported or unaddressed.

section_title: Conclusions
paragraphs: Growth in the percentage of the United States population over 60 years of  age and in reports of elder abuse may outstrip the public resources  allocated to serve the elderly.  In addition, given the range of elder justice  activities and individuals served under federal programs, coordination is  key to ensuring the efficient use of limited resources.  Further, while  federal agencies have taken some initial steps toward coordinating their  elder justice activities, such as forming the Elder Justice Coordinating  Council, their efforts to develop a coordinated response to elder abuse  would be further supported by an assessment of the effectiveness of  federal elder justice programs. Until common objectives and outcomes for  federal elder justice programs are defined, agencies may be working at  cross purposes. In addition, with the continuing growth in the older adult  population, the absence of sufficient public awareness and education  about elder abuse and the resources available to address it may slow the  progress of elder justice efforts at all levels of government.

section_title: Recommendations for Executive Action
paragraphs: 1.  To provide the basis for greater consistency across states in  assessing elder justice service delivery, we recommend that the  Secretary of HHS, as chairman of the Elder Justice Coordinating  Council, direct the Council to make it a priority to identify common  objectives for the federal elder justice effort and define common  outcomes.  2.  To help protect older adults from all forms of abuse, we recommend  that the Secretary of HHS and the Attorney General collaborate in  developing a national campaign to raise awareness of the occurrence  of elder abuse and provide information on how to obtain services.

section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS and Justice, the two federal  agencies that administer the 12 elder justice programs that we reviewed.    HHS provided general comments that are reproduced in appendix III.

Both departments provided technical comments, which we incorporated  as appropriate.

HHS concurred with our recommendations and agreed that federal  coordination is key to ensuring the use of limited resources. Concerning  the first recommendation, HHS identified the formation of the Elder  Justice Coordinating Council as an effort to develop common objectives  and plans for action to address elder justice issues.  Further, HHS said  that each of nine proposals for action that the Council now is considering  has specified outcomes and that steps and strategies are being  developed to implement the proposals.  We agree that the Council’s  activity is indicative of progress toward a coordinated federal elder justice  effort and development of common objectives.  We encourage the  Council to think broadly in developing common objectives and outcomes  that will encompass the elder justice programs of all federal agencies  represented on the Council, both now and in the future.  HHS said that  our recommendations correctly point out a need for greater public  awareness and, with regard to the second recommendation, that one of  the proposals for Council action is development of a broad-based public  awareness campaign.

HHS also asked us to consider that improved public surveillance could  help better describe the extent and patterns of abuse among older adults.   In our previous report on elder abuse, we noted that, although the CDC  considers elder abuse a growing public health problem, there is no  ongoing surveillance of its extent similar to periodic national incidence  studies of child abuse and neglect. Without periodically measuring the  extent of elder abuse nationwide, it will be difficult to develop an effective  national policy for its prevention as required under the OAA. In that  report, we suggest that Congress consider mandating the Secretary of  HHS to conduct, in coordination with the Attorney General, a periodic  national study of the extent of elder abuse over time.

We are sending copies of this report to the appropriate congressional  committees, the Secretaries of the Departments of Health and Human  Services and Justice, and other interested parties. We will also make  copies available to others on request. In addition, the report will be  available at no charge on GAO’s website at http://www.gao.gov. If you  or your staff have any questions about this report, please contact me at  (202) 512-7215 or brownke@gao.gov. Contact points for our Office of  Congressional Relations and Public Affairs can be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix VI.

section_title: Appendix I: Scope and Methodology for Surveying Federal Elder Justice Program Managers
paragraphs: This appendix discusses the methodology for surveying federal elder  justice program managers to gather information for examining the  potential for fragmentation, overlap, and duplication among federal elder  justice programs.

Using lists of existing federal programs, we identified programs  government-wide that funded elder justice activities, based on program  selection criteria discussed below. We confirmed the list through contact  with federal agency officials.  We surveyed the federal officials who  manage the federal elder justice programs on our list, and analyzed the  programs’ similarities and differences with regard to key elements,  including objectives, activities, funding mechanisms and recipients, target  populations, outcome measures and fiscal year 2011 obligations.
subsections: section_title: Identification of Federal Elder Justice Programs
paragraphs: For the purposes of this study, we defined elder justice as efforts to  prevent, identify, and respond to elder abuse. To identify federal  programs that provided funding for elder justice activities in fiscal year  2011, we developed an initial list of programs that met our definition of  elder justice and one of three selection criteria, as shown in figure 4.

The list was based on the findings of three prior inventory efforts  completed by GAO and the Congressional Research Service in 2011, as  well as searches of the Catalog of Federal Domestic Assistance and  agency websites. To confirm the programs on our list, we contacted  agency officials who managed the programs during our entrance  conferences for additional program information. We also asked agency  officials to add any programs that we had overlooked in developing the  list. We then reassessed the list to determine how well the programs met  the elder justice definition and program selection criteria.

section_title: Survey of Federal Elder Justice Program Managers
paragraphs: To determine how federal programs that target elder justice compare with  respect to key elements, we developed a web-based survey to collect  descriptive information about programs from agency officials. Because  program obligations during fiscal year 2011 was one of the data elements  we needed to collect, the survey was designed to collect information from  programs that either have elder justice as a primary objective or one of  multiple objectives.

To develop the survey questions, we reviewed prior GAO reports on elder  justice, on serving the aging population, and on identifying duplication and  overlap in federal programs administered by multiple agencies. The  survey, modeled after GAO surveys regarding potential overlap and  duplication, collected information on key program elements pertaining to  overlap and duplication, including objectives, activities, target populations,  outcome measures, and obligations during fiscal year 2011. The survey  was administered between July and September 2012. To maximize  response, we sent periodic follow-up emails to all agency officials that  had not responded to the survey by our deadline.

The practical difficulties of conducting any survey may introduce several  types of errors, commonly referred to as non-sampling errors. For  example, differences in how a particular question is interpreted, the  sources of information available to respondents, or the types of people  who do not respond can introduce unwanted variability into the survey  results. We included steps in the survey design, data collection, and data  analysis to minimize such non-sampling errors. In designing the survey,  we took steps to clarify the survey questions to ensure that questions  would be correctly interpreted by respondents. For example, during its  development, we pretested our Web-based survey with five selected  programs administered by HHS, Justice, and the SEC. We conducted  these pretests to ensure that the respondents understood the questions  and could provide the answers to them and the questions could be  completed in a reasonable amount of time. Following each pretest, the  survey underwent additional, mostly minor, revisions, based on feedback  from pretest participants. An additional source of non-sampling error can  be errors in computer processing of the data and statistical analysis. All  computer programs relied on for analysis of this survey data were  independently verified by a second analyst for accuracy.

The survey response rate was 100 percent. In addition to collecting  program information, the survey allowed us to confirm, exclude, and add  programs based on consultations with agency officials. As a result of our  analysis of the survey data, including follow-up contact with the agency  officials who managed them, we identified 12 programs that met one of  the first two selection criteria and funded elder justice activities in fiscal  year 2011. We analyzed whether similarities and differences in the 12  programs with respect to key program elements, such as sponsoring  agency, objectives, activities, target populations and grant recipients,  indicated potential overlap or duplication, and whether program officials  could identify program outcomes.

To augment the survey data, we collected additional information on  program activities and target groups for individual activities. We reviewed  program descriptions published on agency websites, in grant solicitations,  and in budget justifications; and reviewed publicly available lists of grant  recipients and award amounts. We then grouped activity descriptions by  type of activity and specific group or subpopulation that directly benefited  from the activity. For example, we determined whether education and  outreach efforts were directed at the general public or a specific  subpopulation of victims of elder abuse, such as those in tribal  communities. We confirmed these classifications with the relevant  program officials and added or corrected information as necessary.

section_title: Appendix II: Federal Elder Justice Programs
paragraphs: Services to End Violence  Against and Abuse of  Women Later in Life  Program  agency staff, and victim assistants to address elder abuse, neglect,  and exploitation, including domestic violence, dating violence,  sexual assault, and stalking, in their communities.

Develop or enhance a coordinated community response to elder  abuse.

Provide or enhance services for victims who are 50 years of age or  older.

Conduct cross-training for victim service organizations,  governmental agencies; criminal justice professionals; and  nonprofit, nongovernmental organizations serving victims of elder  abuse, neglect, and exploitation, including sexual assault, domestic  violence, dating violence, and stalking, in their communities.

Examples of elder justice activities:

Develop multidisciplinary partnerships that include law  enforcement, prosecutors, domestic violence victim services  programs or nonprofits, and programs or nonprofits that serve older  victims.

Training for law enforcement officers, prosecutors, judges, and  individuals that serve older victims and work in victims services  programs.

Cross training for victim services organizations, governmental  agencies, courts, law enforcement agencies, and organizations  working with older victims.

Outreach and service delivery to older victims.
subsections: section_title: Department/ agency HHS/ACL
paragraphs: Fiscal year 2011  obligations  $5,033,000  for the prevention, detection, assessment, and treatment of,  intervention in, investigation of, and response to elder abuse,  neglect, and exploitation, including financial exploitation.

Examples of elder justice activities:

Training law enforcement officers, health care providers, and other  professionals on how to recognize and respond to elder abuse.

Support outreach and education campaigns to increase public  awareness of elder abuse and prevention, including financial  exploitation.

Support efforts of state and local elder abuse prevention coalitions  and multidisciplinary teams of agencies and organizations that work  with victims.

Promote the development of information and data systems,  including elder abuse reporting systems, to quantify the extent of  elder abuse in each state and analyze information to identify unmet  service and need.

Provide technical assistance to programs that provide services for  victims of elder abuse and their families.

Objectives:

Develop comprehensive outreach strategies and foster improved  culturally appropriate crime victim assistance services to address  elder abuse.

Augment ongoing crime victim assistance service strategies and  provide special focus on elders including enhanced collaboration  and coordination among victim assistance and human services,  courts and law enforcement, and community development and  youth outreach and mentoring programs.

Link the issue of elder abuse in tribal communities with traditional  cultural norms of respect and reverence for tribal elders.

Examples of elder justice activities:

Conduct outreach through awareness posters, service brochures,  editorials and newspaper articles, radio and television ads, videos,  and fact sheets.

Support curriculum development, training, community teaching, and  awareness efforts.

Promote community-based and culturally specific crime victim  assistance services and develop and distribute related protocols  and toolkits.

section_title: Department/ agency HHS/NIH
paragraphs: Fiscal year 2011  obligations  $1,134,000  o Epidemiological study of the relationship of self-neglect and  important health outcomes in a biracial population of older  adults.  o Study of relevant health issues, including elder mistreatment, in  older Chinese adults.  o Development of a mentoring program for aspiring researchers  on aging topics.  o Study to determine the extent and outcomes of resident-to- resident elder mistreatment in long-term care facilities.  o Studies of the social and neural bases for older adults’  vulnerability to financial exploitation.

Objective:

Provide information, materials, and support to enhance state and  local efforts to prevent and address elder mistreatment.

Examples of elder justice activities:

Disseminate information about elder abuse prevention, including  promising practices and interventions, and provide resources to  professionals and the public.

Provide technical assistance, training, and consultation, to state  agencies and community-based organizations.

Advise on program and policy development.

Objective:

Support and coordinate Justice's activities in combating elder  abuse, neglect, and financial exploitation, especially as they impact  beneficiaries of Medicare, Medicaid, and other federal health care  programs.

Examples of elder justice activities:

Prosecute failure of care, health care fraud, and consumer fraud  cases and enforce civil rights.

Promote state and local coordination through state working groups.

Provide training for U.S. Attorney’s offices and Medicaid Fraud  Control Units on investigating and developing failure of care cases.

Provide training for nurses, prosecutors, judges, and participants of  legal aid clinics on fraud and abuse cases.

section_title: Department/ agency HHS/ACL
paragraphs: Fiscal year 2011  obligations  200,000  programs across the country, with a primary focus on the older  population, by providing APS systems, agencies, and professionals  with relevant information and support.

Examples of elder justice activities:

Identify evidence-based practices for APS programs and  interventions and promote the evaluation of unevaluated practices  that have the potential to advance and strengthen the efficiency,  effectiveness, and relevance of APS work.

Compile and synthesize research that informs APS programming  and interventions.

Provide specific and targeted technical assistance to state and local  APS programs to facilitate the implementation of best practices and  research findings.

ACL is broadly responsible for federal efforts related to elder abuse and prevention services. In  addition to administering individual programs, ACL is responsible for facilitating the development,  implementation, and improvement of a coordinated, multidisciplinary elder justice system; providing  federal leadership to support state efforts to carry out elder justice programs; establishing an  information clearinghouse; and promoting collaborative efforts for the development and  implementation of elder justice programs. 42 U.S.C. § 3011(a).

Objective(s) and examples of elder justice activities  Objectives:

Support communities in their efforts to develop and strengthen  effective law enforcement and prosecution strategies to combat  violent crimes against women, including older women.

Develop and strengthen victim services in cases involving violent  crimes against women, including older women.

Examples of elder justice activities:

Provide training for law enforcement officers, judges, other court  personnel, prosecutors, and domestic violence victim service  providers to more effectively identify and respond to violent crimes  against women.

Develop and implement more effective police, court, and prosecution  policies and protocols regarding violent crimes against women.

Develop data collection and communication systems linking police,  prosecutors, and courts to identify and track arrests and violations.

Support statewide multidisciplinary efforts to coordinate the response  of state law enforcement agencies, prosecutors, courts, victim  services agencies, and other state agencies.

Provide training for sexual assault forensic medical examiners in  collecting evidence.

Strengthen programs that address violence against older women and  women with disabilities, including investigating and prosecuting  instances of violence and targeting outreach, counseling, and other  victim assistance services.

Objective(s) and examples of elder justice activities  Objectives:

Encourage state, local, and tribal governments and courts to treat  domestic violence, dating violence, sexual assault, and stalking,  including instances of violence against older individuals, as serious  violations of criminal law.

Interpersonal Violence  within Families and Among  Acquaintances Prevention  improve safety, access to services, and confidentiality for victims and  families.  Objective:

Prevent interpersonal violence – including domestic violence, sexual  assault, spousal and partner abuse, and elder abuse, woman  battering, and acquaintance rape – within families and among  acquaintances.

Examples of elder justice activities:

Develop uniform definitions and recommend data elements for public  health surveillance of elder abuse and neglect.

Provide information and education to the public on interpersonal  violence to increase awareness of related public health  consequences.

Provide training to health care providers to identify potential victims of  interpersonal violence and refer individuals to entities that provide  supportive services.

Objectives:

Advocate for residents of nursing homes, board and care homes,  assisted living facilities, and similar adult care facilities and improve  residents’ care and quality of life.

Resolve problems of individual residents.  Examples of elder justice activities:

Investigate and resolve complaints made by residents of facilities.

Provide training to state and local ombudsmen.

Provide consultations to LTC facility managers and staff.

section_title: Department/ agency HHS/ACL
paragraphs: LTC ombudsman programs to enable them to effectively respond to  residents’ complaints and represent their interests on an individual  and systemic level.

Strengthen the LTC Ombudsman program by developing innovative,  effective approaches for states to provide services to LTC facility  residents.

Examples of elder justice activities:

Provide technical assistance to state and local ombudsmen.

Provide consultation, information, and referral for ombudsmen,  residents, and families.

Provide training and resources for state and local ombudsman  programs.

Promote public awareness on the role of ombudsmen.

Identify research needs and promote research related to ombudsman  programs and services.

Promote cooperation between ombudsman programs and advocacy  groups.

Objective(s)  Educate consumers and businesses about  their rights and responsibilities, including  providing consumers with tools needed to  make informed decisions and businesses  with tools needed to comply with law.

Enforce consumer protection laws in  federal court or administrative litigation,  especially in cases alleging deceptive  practices;  coordinate joint law enforcement  actions with state and federal partners,  including criminal law enforcement; enforce  injunctions and administrative orders  obtained in consumer protection cases; and  develop, review, and enforce consumer  protection rules.

Examples of activities related to  elder justice  Provides free information to  consumers of all ages. The FTC  identifies older adults as a target  population for many of its consumer  education efforts, including how to  recognize and report identity theft and  scams/frauds related to health care  and financial exploitation.  The Bureau of Consumer Protection  has investigated frauds affecting  seniors, and misrepresentations  aimed at the “oldest old” and their  caretakers, including  misrepresentations of services  provided when referring seniors to  long-term care facilities.

Collect consumer complaint data and share  information to enable state and local law  enforcement to become more effective.

Collects and stores information on  consumer complaints, including  financial exploitation incidents such as  investment fraud and identify theft.  Complaints may include those  reported by older individuals, though  the FTC does not require complaints  to include the age of the victim.

Provide assistance to states, U.S.  territories, and tribal governments, to  provide services and activities to reduce  poverty.

Grants support activities that address  nutrition, health, and emergency  services, among others, for low- income individuals including the  elderly.

Reduce or eliminate dependency; achieve  or maintain self-sufficiency for families; help  prevent neglect, abuse, or exploitation of  children and adults; prevent or reduce  inappropriate institutional care; and secure  admission or referral for institutional care  when other forms of care are not  appropriate.

Grants may be used to support  activities aimed at preventing neglect,  abuse, or exploitation of children or  adults, among others.

section_title: Department/ agency HHS/ACL
paragraphs: Objective(s)  Provide formula grants to states to support  services that enable seniors to remain in  their homes for as long as possible.

Examples of activities related to  elder justice  Services may include case  management and legal services,  among others. Each state may  allocate funds to area agencies on  aging, which have the flexibility to use  the funds to provide the services that  best meet the needs of seniors in their  service areas. In providing community  services, providers could observe and  report on potential elder abuse  activity.

Promote and enhance state leadership in  securing and maintaining legal rights of  older individuals and state capacity to:  coordinate the provision of legal assistance,  provide technical assistance and training;  promote financial management services for  older individuals, assist  older individuals in  understanding their rights, and improve the  quality and quantity of legal services  provided to older adults.

The legal assistance developer can  play a key role in designing and  implementing the elder rights  provisions of state plans to ensure  older persons have access to their  benefits and rights.

Provide assistance for older individuals in  accessing long-term care options and other  community-based services; protect older  individuals against direct challenges to their  independence, choice, and financial  security.

Services are specifically targeted to  older individuals with economic or  social needs. Services may include  assistance to ensure elder rights  protections regarding transfers from  LTC facilities to home and community- based care and assistance for  individuals who have experienced  elder abuse, including consumer fraud  and financial exploitation.

Provide funding to strengthen states’ legal  services networks, including the  development and implementation of  integrating low-cost service mechanisms.

Grants support legal education and  assistance services and may include  projects that address elder financial  exploitation. The program also  promotes linkages with service  providers in area aging agencies,  Aging and Disability Resource  Centers, state long-term care  ombudsmen, and APS.

Provide grants to states to assist family and  informal caregivers to care for loved ones  at home for as long as possible.

Services include dissemination of  information about services and other  assistance including counseling and  training.

section_title: Department/ agency HHS/ACL
paragraphs: Objective(s)  Support the aging and legal networks to  enhance the quality, cost effectiveness, and  accessibility of legal assistance and elder  rights programs; and support demonstration  projects to expand or improve the delivery  of legal assistance and elder rights  protections to older individuals with social  or economic needs.

Examples of activities related to  elder justice  Supported activities include case  consultation for legal professionals  regarding legal problems impacting  older individuals, training for aging  and legal services professionals on a  range of legal and elder rights issues,  technical assistance to professionals  that provide legal assistance to older  individuals, and information  dissemination regarding legal and  elder rights issues.

Nutrition Services  (Congregate Nutrition  Services, Home-Delivered  Nutrition Services and  Nutrition Services Incentive  Program)

Reduce hunger and food insecurity,  promote socialization of older individuals,  and promote the health and well-being of  older individuals and delay health  conditions through access to nutrition and  other disease prevention and health  promotion services.

Grants to states support nutrition  services including meals and nutrition  education. In providing or delivering  meals, service providers could  observe and report on potential elder  abuse activity.

Promote the financial security of older  individuals and enhance their choice and  independence by empowering them to  make decisions with respect to pensions  and savings plans.

Projects include assisting seniors with  the administrative appeals process,  locating pension plans “lost” as a  result of mergers and acquisitions,  and other assistance in negotiating  with former employers for due  compensation.

Provide culturally competent health care,  community-based long-term care, and  related services; serve as focal points for  developing and sharing technical  information and expertise for organizations,  communities, educational institutions, and  professionals working with older Native  Americans.

Center activities have included  assisting in developing community- based solutions to improve the quality  of life and delivery of support services  to the Native elderly population and  providing a forum for discussions  about elder abuse to help  communities develop plans to reduce  and control occurrences.

Empower seniors to protect themselves  from the economic and health-related  consequences of Medicare and Medicaid  fraud, error, and abuse through increased  awareness and understanding of health  care programs.

Activities include training Medicare  beneficiaries, retired professionals,  and other senior citizens on how to  recognize and report instances or  patterns of health care fraud and  abuse and complaint resolution for  beneficiaries.

Identify efficient, effective, and economical  procedures for LTC facilities and providers  to conduct background checks on a  statewide basis on all prospective direct  patient access employees.

States conduct background checks to  help meet regulations prohibiting LTC  facilities and providers from employing  individuals found guilty of abuse,  neglect, or misappropriation of patient  funds.

section_title: Department/ agency HHS/CMS
paragraphs: Objective(s)  Receive complaints, grievances, and  requests for information from, and provide  assistance to, Medicare beneficiaries.

Examples of activities related to  elder justice  The ombudsman may receive  inquiries or complaints that mention  elder abuse and refer complainants to  the appropriate agency or  organization to address their  concerns.

Determine whether service providers and  suppliers meet applicable requirements for  participation in Medicare and/or Medicaid  programs, and are incompliance with  Medicaid and Medicare conditions of  participation and coverage.

Federal and state surveyors conduct  health and safety inspections in a  variety of settings, including nursing  homes, home health agencies, and  hospitals, to determine compliance  with CMS regulations including those  that address abuse and neglect of  beneficiaries.

Train and educate individuals in providing  geriatric care for the elderly.

Activities include training,  development of curricula related to the  treatment of health problems of the  elderly, continuing education, and  establishment of traineeships for  advanced education students.

Support the career development of  physicians, nurses, social workers,  psychologists, dentists, pharmacists, and  health professionals as academic geriatric  specialist by requiring them to provide  training in clinical geriatrics, including the  training of interdisciplinary teams of health  professionals.

Faculty teaches and develops skills in  interdisciplinary education geriatrics.

Establish or operate Geriatric Education  Centers to provide interdisciplinary training  of health professional faculty, students, and  practitioners in the diagnosis, treatment and  prevention of disease, disability, and other  health problems of the elderly.

Project activities include training and  continuing education of health  professionals in geriatrics and  developing curricula related to the  treatment of health problems of the  elderly.

Provide support, including fellowships, for  geriatric training projects to train  physicians, dentists and behavioral or  mental health professionals who plan to  teach geriatric medicine, geriatric dentistry,  or geriatric behavioral or mental health.

Physicians participate in service  rotations that include day and home  care programs, extended care  facilities, and community care  programs.

Provide eligible homeowners with  education and information about the unique  features of a reverse mortgage and other  alternatives to a reverse mortgage that  homeowners may consider given their  financial situation.

HUD offers counseling to elderly  clients who may be at risk of  delinquency in paying mortgages and  may be at risk of becoming victims of  financial exploitation.

Objective(s)  Extend the length and improve the quality  of independent living and prevent  premature and inappropriate  institutionalization of elderly and disabled  non-elderly residents of federally-assisted  multifamily housing.

Examples of activities related to  elder justice  Service coordinators assess resident  needs; identify and link residents to  appropriate services in the  community, and monitor the delivery  of services. Service coordinators may  also educate residents about other  services and help them build informal  support networks.

Link public housing residents with  supportive services, resident empowerment  activities, and assistance in becoming  economically self-sufficient. For elderly or  disabled residents specifically, the objective  is to help improve living conditions and  enable residents to age-in-place.

Service coordinators assess the  needs of residents and coordinate  available resources, including  supportive services for elderly  residents.

Address the most serious tribal law  enforcement needs; increase the capacity  of tribal law enforcement agencies to  prevent, solve, and control crime for safer  communities; implement or enhance  community policing strategies; and engage  in strategic planning for law enforcement.

Grants support law enforcement  training, including community policing  and computer and crime reporting  training.

Encourage and support research,  development, and evaluation to further  understanding of the causes and correlates  of crime and violence, methods of crime  prevention and control, and criminal justice  system responses to crime and violence;  and contribute to the improvement of the  criminal justice system and its responses to  crime, violence, and delinquency.

Projects include research related to  elder mistreatment as it relates to the  objectives of the program, such as  identifying the causes and means of  preventing crime.

Enhance the systemic response to crimes  of domestic violence, dating violence,  sexual assault, and stalking committed  against American Indian and Alaska Native  women and girls.

Victim services provided under the  program, including emergency shelter  services, crisis intervention, and  information and referrals, may be  provided to older individuals who are  victims.

Provide investor protection through the  prosecution of violations of federal of  securities laws.

Prosecuted cases may include those  involving older adults as victims.  In  some instances, the elderly were  specifically targeted.

Provide information to investors about  protecting their finances, funds and  investments, and ways regulators can  support their efforts.

While most outreach activities are  targeted at all investors, there are  several activities, throughout the  country, that are specifically focused  on senior investors, such as Senior  Summits, Senior Days and Senior  Expos.

Objective(s)  Engage in outreach activities on an ad hoc  basis.

Examples of activities related to  elder justice  Past activities have included SEC’s  Senior Summits which help older  investors make difficult decisions  about their finances and learn new  ways to protect their assets as they  age.

Foster compliance with securities laws,  detect violations, and correct compliance  problems by conducting examinations of  registered entities, broker-dealers, and  investment advisers and companies,  among others.

Examinations may identify unsuitable  transactions for senior investors.

Provide investors with information needed  to evaluate current and potential  investments, make informed decisions, and  avoid fraudulent schemes. In addition,  provide agency staff with critical insight  about emerging trends and factors shaping  investor decision-making.

OIEA may target certain outreach  efforts to specific groups, such as  seniors, members of the military, and  teachers. Outreach includes providing  resources to help individuals become  better-educated investors, including  understanding how to avoid fraud. For  example, OIEA continues to support  the Outsmarting Investment Fraud  Campaign, designed to educate  seniors about identifying potential  investment fraud.

Communicate money laundering or terrorist  financing risks to the financial industry and  facilitate the reporting of valuable  information to law enforcement.

FinCEN issued an advisory to  financial institutions in 2011 that  provided potential indicators of elder  financial exploitation.

section_title: Appendix III: Comments from the U.S. Department of Health and Human Services

section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments:
paragraphs: In addition to the contact listed above, individuals making key  contributions to this report, in all aspects of the work, were Bill  Keller, Sara Edmondson, Brenna Guarneros, and Rosemary Torres  Lerma. Also contributing to the report were James Bennett, Holly  Dye, Melissa Jaynes, Jill Lacey, Grant Mallie, Amanda Miller,  Andrew Nelson, Heddi Nieuwsma, and Craig Winslow.

section_title: Related GAO Products
paragraphs: Elder Justice, National Strategy Needed to Effectively Combat Elder  Financial Exploitation. GAO-13-110. Washington, D.C.: November 15,  2012.

Elder Justice: Stronger Federal Leadership Could Enhance National  Response to Elder Abuse. GAO-11-208. Washington, D.C.: March 2,  2011.

Older Americans Act: More Should Be Done to Measure the Extent of  Unmet Need for Services. GAO-11-237. Washington, D.C.: February 28,  2011.


Question-summary annotations: questions: question: What did the departments of HHS and Justice administer in 2011?
answer: In fiscal year 2011, two agencies--the Departments of Health and Human Services (HHS) and Justice (Justice) --separately administered 12 fragmented but minimally overlapping programs that directed funds toward elder justice, with low risk of duplication.
child_questions: question: What characterized the separate administration of these programs?
answer: Specifically, because more than one federal agency administers these programs, GAO found that these grant programs are fragmented. Further, GAO found that overlap across the 12 programs was minimal because the programs varied with respect to (1) funding mechanisms and recipients, (2) elder abuse victims targeted, (3) service providers, and (4) activities conducted.

question: How did the funding among the programs differ?
answer: For example, a few of these programs provided formula grants to all states and most dispersed discretionary grants to a limited number of recipients. Programs that supported victims of elder abuse generally assisted all types of victims, but some also focused on certain subgroups, such as older women.

question: How were judges and court personnel included in some of the programs?
answer: Some programs that assisted service providers also targeted specific subgroups, such as judges and court personnel.

question: What did support among elder justice programs look like?
answer: In addition, elder justice programs supported a wide range of activities. For example, one HHS program provided public education to help identify and prevent elder abuse, while a Justice program trained law enforcement officers to investigate instances of elder abuse.

question: How do the differences across programs affect the risk of overlap among them?
answer: Considering the variation across funding mechanisms and recipients, the elder abuse victims and service providers targeted by the grants, and the types of activities conducted, overlap across the 12 programs is minimal and the risk of duplication--when two or more agencies or programs are engaged in the same activities or provide the same services to the same beneficiaries--is low.

questions: question: Why is coordination important to elder justice work?
answer: We have previously reported that coordination is key to ensuring the efficient use of limited resources to address issues that cut across more than one agency.
child_questions: question: What would help federal coordination efforts?
answer: While federal coordination is in development--for example, HHS, Justice, and other agencies recently formed the Elder Justice Coordinating Council--federal agencies have yet to articulate common objectives and outcomes as precursors to future measures for elder justice programs, which would provide a rationale for coordination.

question: :How has a lack of tracking program outcomes hindered efforts to stop elder abuse?
answer: Further, few federal programs tracked elder justice outcomes in 2011 or conducted program evaluations to assess effectiveness, making it difficult to determine what impact, if any, many programs have on victims of elder abuse.

questions: question: What is a major challenge in meeting the needs of the elder population?
answer: Officials representing state aging agencies, area agencies on aging and service providers in the three states GAO visited identified the increased demand for elder justice services in a constrained fiscal environment as a major challenge in meeting the needs of the growing older adult population.
child_questions: question: How can existing programs better prevent elder abuse?
answer: Officials also cited the need for greater awareness of elder abuse by the public and training of direct service providers who interact with older adults on a regular basis, to help prevent elder abuse or recognize its symptoms.

question: To what extent is public awareness necessary for this issue?
answer: Five of the nine regional agency officials GAO spoke with said elder justice issues need to be elevated to national attention for the general public by a national public awareness campaign.
child_questions: question: As such, what is the Elder Justice Coordinating Council considering?
answer: The Elder Justice Coordinating Council is considering a recommendation to sponsor a national campaign but has not yet done so.

questions: question: What are the current challenges facing the elder justic movement?
answer: As the percentage of older adults in the population increases, the number of older adults at risk of abuse also is growing. At the same time, constraints on public funds may limit assistance to the growing population of older adults in need.
child_questions: question: What was GAO asked to do as a result of these concerns?
answer: GAO was asked to review elder justice program issues.
child_questions: question: What three main points does GAO cover in their report?
answer: This report addresses: (1) the extent to which there is fragmentation, overlap, or duplication across the federal grant programs that support elder justice; (2) the extent to which federal programs coordinate their efforts and monitor elder justice outcomes; and (3) how state aging agencies, area agencies on aging, and service providers deliver federal elder justice services and what challenges, if any, they face in doing so.

question: In writing this report, what sort of information did GAO gather?
answer: GAO reviewed relevant federal laws and regulations, identified federal elder justice programs, surveyed federal officials about program elements, reviewed program documentation, and visited agencies responsible for elder justice in Illinois, Virginia and Arizona.

question: How did GAO select the states they reviewed?
answer: GAO selected states based on the percentage of the elderly in the state population, geographic dispersion, and percentage of the state's Older American Act funds devoted to elder care.