UNIT DVALUATION DES TECHNOLOGIES ET DES MODES DINTERVENTION HOW TO SUPPORT PROFESSIONAL CARE PROVIDERS IN THE DETECTION OF OLDER ADULT MISTREATMENT Mlanie Couture, Ph.D. Researcher and coordinator of the ETMI unit, Integrated Health and Social Services University Network for West-Central Montreal Sarita Isral Coordinator of the cutting-edge practice to counter mistreatment of older adults Integrated Health and Social Services University Network for West-Central Montreal Midi-CREGS Montreal, October 27th 2015 INTRODUCTION Prevalence of older adult mistreatment : 10% in cognitively intact older adults to 47% in older adults with dementia (Acierno et al., 2010; Wigelsworth et al., 2010) Social and health care professionals are well positioned to witness or prevent older adult mistreatment Majority of mistreated older adults are already clients of health and social services (Sandmoe & Kirkevold, 2010) Qualified to: identify potentially hazardous environments; resolve underlying issues; provide additional services; involve other family members (Dong, 2013) OBJECTIVES OF THE PRESENTATION In relation to older adult mistreatment: 1.DESCRIBE THE DECISION MAKING PROCESS RELATED TO IDENTIFYING SITUATIONS OF MISTREATMENT 2.HIGHLIGHT STRATEGIES TO BETTER SUPPORT CARE PROVIDERS IMPORTANT DEFINITIONS DEFINITIONS OLDER ADULT MISTREATMENT Older adult mistreatment is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. (Adapted from World Health Organization, 2002) DEFINITIONS FORMS OF OLDER ADULT MISTREATMENT Violence Treat an older adult badly or force an older adult to act against his/her will, through the use of force and/or intimidation. Neglect Fail to show concern for an older adult, in particular due to a lack of appropriate action for meeting his/her needs. DEFINITIONS INTENTION OF THE PERSON WHO MISTREATS Intentional mistreatment The person who is mistreating an older adult wants to harm him/her. Unintentional mistreatment The person does not want to harm the older adult or does not understand the harm being caused. DEFINITIONS TYPES OF OLDER ADULT MISTREATMENTPsychologicalPhysicalSexualMaterial or financialViolation of rightsOrganizationalAgeism DEFINITIONS CONTINUUM OF CARE FOR OLDER ADULT MISTREATMENT CASESIdentificationReportingInvestigationAssessmentClient consentIntervention (Couture et al., 2015) DEFINITIONS IDENTIFICATION OF POSSIBLE MISTREATMENT SITUATIONS Purposefully documenting and analyzing signs of older adult mistreatment and/or risk factors using clinical judgment or screening instruments in an effort to detect possible mistreatment cases (Couture et al., 2015) DEFINITIONS PURPOSEFULLY DOCUMENTING Mistreatment is contextualized within a trusting relationship between the older adult and the person that mistreats Based on the assumption that the person that is being mistreated will not easily come forth DEFINITIONS DETECT POSSIBLE MISTREATMENT SITUATIONS Start of the continuum of care Purpose to identify potential mistreatment situations that would normally go unnoticed Prevent the situation from escalating Different from investigation where the process aims at determining whether the mistreatment situation is substantiated or not WHAT IS THE DECISION MAKING PROCESS BEHIND THE IDENTIFICATION OF OLDER ADULT MISTREATMENT? DECISION-MAKING PROCESS IN GENERAL, A DECISION MAKING PROCESS IS: Cognitive process resulting in the selection of a course of action among several alternative scenarios Taking into account: Needs Context Knowledge Emotions, preferences, values Relationship-based DECISION-MAKING PROCESS IDENTIFICATION OF POTENTIAL MISTREATMENT SITUATIONS 1.Is this a possible situation of older adult mistreatment? 2.How much at risk is the older adult? 3.What do we do next? (Couture et al., 2015) IS THIS A POSSIBLE SITUATION OF OLDER ADULT MISTREATMENT? DOCUMENTING SIGNS OF MISTREATMENT RISK FACTORS OF MISTREATMENT The more risk factors, the more the person is vulnerable And increases the probability of mistreatment IS THIS A POSSIBLE SITUATION OF OLDER ADULT MISTREATMENT? Examples of signs of mistreatment Fear Injuries, deteriorating health Sexual disinhibition Unusual banking transactions, disappearance of valuable objects Restriction of visits or access to information Inadequate care Non-recognition of an older adults competencies or knowledge IS THIS A POSSIBLE SITUATION OF OLDER ADULT MISTREATMENT? Specific to the older adult Significant disability Poor physical health Depression Low income or socioeconomic status Cognitive impairment Social isolation (World Health Organization, 2015) IS THIS A POSSIBLE SITUATION OF OLDER ADULT MISTREATMENT? Specific to the person who mistreat Depression Substance abuse (alcohol or drug misuse) Dependence on the mistreated (financial, emotional, relational) Specific to the relationship Living arrangement: older adult lives alone with mistreating person (World Health Organization, 2015) HOW MUCH AT RISK IS THE OLDER ADULT? THREE QUESTIONS THAT MUST BE ANSWERED TO ESTABLISH LEVEL OF RISK Is there an immediate risk to the safety of the person? Is there an impending risk to the safety of the person in the near future? Is this a longstanding or chronic situation that may escalate in the future and increase the risk to the safety of the person? WHAT DO WE DO NEXT? ANALYZING THE DATA Data Signs Risk factors Level of risk Clinical judgment Individual process or in collaboration with others WHAT DO WE DO NEXT? OPTIONS Further assessing the older adult Investigating the situation Reporting the situation to internal management and/or external resources Obtaining consent from the older adult WHAT DO WE DO NEXT? OPTIONS Intervening : Ex. Increasing surveillance, working on risk factors Social, medical, legal aspects Older adult and mistreating person Referral to internal and/or external resources Closing the case HOW TO BETTER SUPPORT CARE PROVIDERS IN THE IDENTIFICATION OF OLDER ADULT MISTREATMENT? BARRIERS TO IDENTIFICATION BARRIERS RELATED TO THE DECISION MAKING PROCESS Complexity requiring multiple areas of expertise (psychosocial, medical and legal aspects) Multiple decision-making processes Presence of diverse perspectives and emotions BARRIERS TO IDENTIFICATION BARRIERS RELATED TO PROFESSIONALS Lack of knowledge/training (McCreadie et al., 2000; McCreadie et al., 1998; Taylor et al., 2006) Believe others are responsible for the identification (Schmeidel et al., 2008) Fear of losing the older adults trust (Schmeidel et al., 2008) Health care professionals confidence in his or her ability to intervene (Killick & Taylor, 2009) BARRIERS TO IDENTIFICATION BARRIERS RELATED TO ORGANIZATION Older adult mistreatment is not a priority (Couture et al., 2014; Stolee et al., 2012) Lack of time (Couture et al., 2014 ; Schmeidel et al., 2008 ) No protocol or knowledge of how or where to record the information related to mistreatment (Couture et al., 2014; Anthony et al., 2009; Stolee et al., 2012) Absence of support from colleagues to discuss the situation (Killick & Taylor, 2009) SUPPORT TRAINING SCREENING TOOLS CLINICAL SUPERVISION SPECIALIZED CLINICAL CONSULTATION SERVICES TYPES OF SUPPORT SUPPORT How to recognize the problem and the signs and where to get more information or support about the problem How to recognize, detect and orient to the right resources How to recognize, detect, and intervene using an interdisciplinary and multi-sectorial approach THREE TRAINING OBJECTIVES ACCORDING TO LEGAL RESPONSIBILIT Y IN INTERVENTION SUPPORT SCREENING TOOLS Structures and supports the data collection process: Helps identify signs and risk factors Facilitates assessment of level of risk Information collected from: Client file (existing documentation) Interviews for with older adult and other relevant third parties (additional information) SUPPORT SCREENING TOOLS Example Risk factor checklist Risk level assesment tool EXAMPLE RISK FACTORS CHECKLIST PRIORITY I IMMEDIATE RISK: INTERVENTION REQUIRED WITHIN 24 HOURS i.e. reported physical violence or imminent threat to safety and security etc. i.e. medical crisis, injury, etc.. i.e. situational incapacity to cope, suicidal intent. Implement emergency measures; No Consent Required when in immediate danger to self and / or others. Contact Police or Relevant emergency services Violence Bio Psycho (http://www.prendreencharge.com/tools-for-professionals/) PRIORITY II IMPENDING RISK; INTERVENTION REQUIRED WITHIN THE 2-10 DAYS Inaptitude to consent and refusal Begin procedure s for substitute consent; monitor for escalation to Risk Level I With consent Proceed with appropriate intervention; provide emergency plan Aptitude to consent and refusal Advise of risk and provide emergenc y plan; monitor for escalation to Risk Level I i.e. decompensating caregiver or mental health of an individual with potential for physical violence i.e. existing barriers to obtain health services resulting in neglect i.e. stressful situational change imminent death or departure of a significant other, etc. i.e. imminent cessation of resources or services; financial respite, etc See Annexe II Violence Bio Psycho Social (http://www.prendreencharge.com/tools-for-professionals/) PRIORITY III NO IMPENDING RISK; LONG TERM IMPACT UPON QUALITY OF LIFE, MORBIDITY AND MORTALITY. i.e. history of family violence without imminent threat i.e. dependency secondary to loss of autonomy within a maladaptive relationship i.e. powerlessness secondary to depression, fear or co-dependency i.e. isolation, poor support structure, unmet needs Inaptitude to consent and refusal Treat as a Risk Level II With consent Proceed with appropriate intervention; provide emergency plan Aptitude to consent and refusal Advise of risk and provide emergency plan; monitor for escalation to Risk Level I or II Violence Bio Psycho Social See Annexe II (http://www.prendreencharge.com/tools-for-professionals/) SUPPORT CLINICAL SUPERVISION Case-focused support, direction and guidance of practitioners by a designated senior/qualified practitioners (Milne, 2007) SUPPORT CLINICAL SUPERVISION EXAMPLE Prior to the meeting : Social and health care professionals review all client files using screening tools to : Identify possible signs of mistreatment and risk factors Evaluate the level of risk SUPPORT CLINICAL SUPERVISION EXAMPLE Supervisor asks: Are there any clients that present risk factors for mistreatment within your caseload? If the answer is yes: What was their level of risk? Which actions must be undertaken and by which actors? Is there more than one client in the potential mistreatment situation? SUPPORT CLINICAL SUPERVISION Role of supervisor: 1)Asking questions to clarify risk factors or signs; Identifying irregularities in the case presentation; 2)Helping to determine the level of risk; SUPPORT CLINICAL SUPERVISION Role of supervisor: 3.Participating in the development of the intervention plan; Confirming the relevancy of prior intervention or planned intervention; Analyzing the reaction of the client or family to prior intervention; Helping to identify other internal or external resources to involve. SUPPORT SPECIALIZED CLINICAL CONSULTATION SERVICES Ligne Aide Abus Ans Elder Mistreatment Helpline Province-wide telephone service (free and confidential) 7 days a week (8 a.m. to 8 p.m.) / ) SUPPORT SPECIALIZED CLINICAL CONSULTATION SERVICES Ligne Aide Abus Ans Elder Mistreatment Helpline Professional consultation service for mistreatment issues/cases Clinical and ethical discussions Identification of the elements to evaluate Suggested avenues for action and intervention priorities (to be validated with your team) SUPPORT SPECIALIZED CLINICAL CONSULTATION SERVICES Ligne Aide Abus Ans Elder Mistreatment Helpline Each call for professional consultation is discussed with the clinical supervisor for Ligne AAA Where necessary, the professionals with Ligne AAA may refer to the Provincial multisectorial consultation team for intervention in older adult mistreatment of West-Central Montreal Health PROVINCIAL MULTISECTORIAL CONSULTATION TEAM OF WEST-CENTRAL MONTREAL HEALTH Social worker Public curator Notary Medical representative Police officers (City police & SQ) Hospital and long- term care facility managers Mistreatment prevention regional coordinator Lawyers in civil law and criminal law Mistreatment prevention community organization Ethicist CONCLUSION Decision-making is a three-step process Many obstacles difficult to overcome without support Support needs to be structured and integrated in practice Older adult mistreatment is complex and may require multisectorial consultation and the referral to specialized resources IDENTIFICATION OF OLDER ADULT MISTREATMENT IS EVERYONES RESPONSIBILITY WITHIN AN ORGANIZATION! IDENTIFICATION IS ONLY THE START OF THE CONTINUUM OF CARE!