San Francisco's Forensic Center: Building PG and APS Collaboration

Talitha GuinnElder Abuse Prevention at IOA

Jill Nielsen, LCSWAdult Protective Services, City and County of San Francisco

Mary Ann Warren, JD Office of the Public Guardian, City and County of San Francisco

Goals of Presentation Explore APS and PG frameworks for protecting vulnerable

adults. Facilitate communication between APS and PG to improve

the quality of APS referrals for conservatorship and to facilitate the investigation process for conservators.

Learn how a multi-disciplinary forensic center model can improve client outcomes and enhance coordination and understanding between the PG and APS.

Learn to build collaboration between the PG and APS.

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Why we are here

To help those who help the vulnerable

How does the Forensic Center improve APS/PG collaboration?

Neuropsych evaluations as valuable tool Cross-training about roles of partner agencies Neutral communication forum Early intervention – allows PG to provide

feedback about information needed and possible alternatives

More appropriate and robust referrals from APS

Our ModelWe are a true public/private partnership

Community-based No medical center or medical model (LA and UCI)

Our partners are representatives from the following agencies: DAAS

APS Public Guardian (PG)

SFPD District Attorney City Attorney Ombudsman IOA – Coordinates FC IOA contracts to provide

Geriatrician Psychologist

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Beginning• Precursors to Forensic Center

– Multidiciplinary Team Meeting (MDT) Started at IOA in 1981

– Multidisciplinary Assessment Team (MAT) starts with vision from IOA, Social Services, Law Enforcement and the DA’s Office

• DA Harris proposed new elder abuse center in SF late 2006

• Planning with all partner agencies

• Funding provided through Archstone Foundation and The City and County of San Francisco

• Launched Jan 2008 – Five Year Anniversary 1/2013!

Forensic Centers• Four Forensic Centers in California

– San Francisco www.sfeafc.org– Orange County www.elderabuseforensiccenter.com– LA www.lacelderabuse.org– San Diego

http://www.sandiego.gov/sandiegofamilyjusticecenter/services

• Three similar models in US outside of CA– Texas

www.uth.tmc.edu/schools/med/imed/divisions/geriatrics/team-institute.html

– New York http://nyceac.com/– Hawaii http://www.elderjusticehonolulu.com/

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Services Forensic Review meetings – Formal case consultation

by our multi-disciplinary team of professionals Coordinated Homevisits – Two or more participating

FC team members go to the client’s home together i.e. Police and an APS social worker, Geriatrician and Geropsychologist

Medical evaluations – Geriatrician evaluates medical/mental status at the request of the team

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Medical record review – Geriatrician reviews to determine medical status/standard of care inquiries

Psychological/Neuropsychological Assessments – Geropsychologist conducts per request of the team

SFPD – Office Hours at APS Collaboration with

community partners and city agencies on elder abuse public awareness campaigns, education to professionals, and protocol.

Services Continued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Forensic Review Meetings Weekly 90 min. meetings at APS office 2-3 times a month

Discuss ~2 new cases and 3 follow up cases on average Referrals of cases from any partner agency

Most initially from APS Case Consultation

Examine case from a multidisciplinary perspective Is this a crime? If so, what is needed for a successful

prosecution? What are our goals? Safety – Harm Reduction – Prosecution

– Referral to other agenciesDiscuss protocols, policy, and other “business”

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Mission Statement

The San Francisco Elder Abuse Forensic Center will prevent and combat the abuse, neglect and exploitation of elders and dependent adults in San Francisco. This will be accomplished with the following strategies:

Improve communication and coordination among the legal, medical, social services professionals who investigate and intervene in cases of elder and dependent adult abuse.

Increase access to potential remedies and justice for those who have been victimized.

Educate policy makers, professionals, caregivers, older adults and their families about preventing, reporting, and stopping elder and dependent adult abuse.

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Benefit to APS and PG Consultation with Geriatrician – Benefit to PG

and APS for case planning purposes Targeted intervention for chronic self-neglect

cases Strategic planning with partner agencies to

manage involuntary aspect of service planning Relationship Building between all Partner

Agencies

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Data Jan 2008 - Present

Abandonment 8Abduction 4Isolation 17Neglect 71physical - assault/ battery 37physical -Chem. Restraint 3physical -Restraint or deprivation3Psychological 60Self-Neglect 62Sexual 5Fin. Real estate 46 Total Financial Abuse 165Fin. Other 119Other/unknown 141 *Undue Influence

576 (multiple types of abuse per case)

Total Meetings (FC & MDT) 144

Psych Clients 127FC Clients 360Total Clients 487

AVG Age 75Med Age 78

# %Men 138 38.33Women 217 60.28Group 5 1.39

360 100.00

Our next data project is mapping abuse by zip code and type!

What Is Adult Protective Services?

Adult Protective Services is a county-based program that intervenes to remedy or reduce danger to dependent adults and elders who are at risk of physical, sexual, mental or financial abuse, neglect or self-neglect.

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Adult Protective Services Mission

To maintain the health and safety of dependent and elder adults in the community, in the least restrictive environment.

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Adult Protective Services Goals

Protect physical well-being of victims. Prevent or intervene to prevent financial

abuse. Prevention education and services. Delay or prevent institutionalization. Maintain independent living. Link community services to reduce

repeated referrals.

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Types of Abuse

Physical Abuse Neglect Psychological Financial Abuse Abandonment Isolation Self Neglect/Inability to

Manage

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APS Interventions

Conduct investigation and forward findings to local law enforcement as appropriate

Arrange for the immediate safety of the individual Develop a plan for the care and safety of the

individual and their property Initiate referral for conservatorship, when

necessary Refer to community agencies and support

resources General advocacy

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Guiding Principles

Respect for self-determination of the client except when a crime has been committed

A victim may refuse/withdraw consent at any time to an investigation or to services by APS, unless a Penal Code Section has been violated

If an individual lacks capacity to give consent or is under the influence of other(s) a petition for temporary conservatorship may be initiated

Least restrictive services

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Public Guardian

To assist older adults and adults with disabilities and their families maximize self-sufficiency, safety, health and independence so that they can remain living in the community for as long as possible and maintain the highest quality of life.

Mission of the Department of Aging and Adult Services

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Probate Conservatorship: What is it?

To protect and care for the person and to administer the estate of those who, without assistance, cannot provide for the basic needs of food, shelter, or clothing or are unable to resist fraud or undue influence

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Conservator of Person

There must be evidence that the proposed conservatee is unable to properly provide for his personal needs for physical health, food, clothing, or shelter

There must be evidence of a correlation between the deficit and the need for conservatorship

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Conservator of the Estate

There must be evidence that the proposed conservatee is substantially unable to manage his financial resources or resist fraud or undue influence.

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Temporary Conservatorship

There must be evidence of an urgent need - such as the need for a medical procedure or the need to safeguard assets in imminent danger of loss.

The probate conservatorship is not renewed automatically; it remains in place unless the conservatee or conservator petitions the Court for termination at any time

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Obstacles for PG Conservators Limited number of placement opportunities. Greater number of clients requiring secure

placements. Increasingly complex financial abuse cases. T-Cons can only be carried out when there is

an urgent need. Changes in requirements about notification to

family members. Cases may be continued without proper notice.

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LPS Mental Health Conservatorship

Individual is determined to be gravely disabled secondary to mental illness and is unable/unwilling to accept treatment

Is going to be treated in a licensed locked psychiatric setting following stabilization of an acute episode

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How to use LPS

Process begins in acute psychiatric setting Petition is filed by MD after 5250 (14 day

hold) has been initiated This provides for a 30 day period to

investigate need for conservatorship and alternatives

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Obstacles for LPS Conservators

Effort to use LPS as a means to provide treatment to chronic substance users

Limited availability of locked programs for mental heath clients who have organic and substance abuse problems concurrently

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Differing Frameworks to Protection

Public Guardian • Option of last resort• Court driven and

highly regulated• Involuntary service

Adult Protective Services• Crisis Oriented• Realigned and loosely

regulated• Voluntary Service

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Similar Frameworks to Protection

Public Guardian Protect clients from

exploitation and abuseLeast restrictive options

for carePromote client well-

being

Adult Protective ServicesProtect clients from

exploitation and abuseLeast restrictive options

for careRight to self-

determination

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Collaborative Interventions through the Forensic Center

Criminal remedies Civil (Probate Conservatorship + referrals) Enhancing safety Medical Psychological Services Expert recommendations Expert witness (med and psych) Outreach

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Abused by daughter“I wish she would die”

Left in bed without blankets, windows open in winter Fell ill and hospitalized, but not for over 5 days FC meeting Emergency psych evaluation Emergency conservatorship Restraining order Placed safely and anonymously

Case Vignette. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Building Collaboration through the Forensic Center

Interdisciplinary Education Learning about the limits of APS authority Role of the probate court for PG cases Medical, social work education for partners such as law

enforcement Common understanding that conservatorship is not

the quick-fix that we all wish it would be.

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Relationships are created and maintained.

Increased contact between APS/PG staff.

Common focus on helping vulnerable clients.

Enhanced understanding about challenges of each program.

Building Collaboration through the Forensic Center

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Improved referral packets from APS APS workers have context for the information

required. Requests for further information made in

neutral setting and APS willing to cooperate. Tools and resources are brought forward during

Forensic Center meetings to assist with referral process.

Positive Outcomes from Collaboration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Avoiding Conservatorship Creative problem-solving happens during Forensic Center

meetings. Conservatorship seen by all as measure of last resort.

Geriatrician provides increased access to SF General Hospital to enhance safety

Use of 2900 to protect assets Contacting regulatory boards for follow up on

abusers

Positive Outcomes from Collaboration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Efficiency More direct contact between agencies with

less run around Medical consultations Psychological evaluations eases

conservatorship process and better care plans.

Added Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Advocacy Informed by CollaborationRecognized need for caregiver trainingEnd of life care educationDeveloped a newsletter to raise awareness about

scamsPolice educationBus Shelter Ads

Added Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Challenges • On-going Education Needed

-Rotation of Forensic Center partners-Refreshers needed for APS/PG staff

• Demonstrating the Efficiency Aspect of the Forensic Center to all partners

• Arriving at Consensus about Client Interventions

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Challenges

• Lacking Necessary Tools - Depending on “Watchful Waiting”

• Challenging Client Portraits

• Building a Team-Engaging assigned representatives and maintaining their engagement.

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Case Study

$40,000 overseas so that the taxes and handling fees would be covered. He mentioned this to the bank teller as he exited the bank with a money order in hand. The bank teller called APS. APS knew who to call at SFPD, the PG, and the DA’s office. That same day, the police were able to intercept the payment at FedEX before it went out, and saved Mr. W’s life savings. The PG prepared and served a “2900” on the bank to marshal his assets. The PG then petitioned for conservatorship after obtaining a psychological evaluation through the Forensic Center.

Mr. W. thought he won the lottery. All he had to do was send

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There’s an App for that!Go to your app store and search ‘368’

App update. Over 2150 downloads!

Boulder County Area Agency on Aging andWilliam Mitchell College of Law in MinnesotaAre creating an app based on our model.

IOA exploring funding for app updates and developing an app for the general public. http://www.centeronelderabuse.org/368ElderAbuseCA.asp

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Elder financial abuse can be both a civil wrong and a crime. Civil remedies primarily seek to help victims recover from the consequences of exploitation; criminal sanctions seek to punish and deter such wrongful conduct. both serve important public policy objectives and promote the legislature’s goal of reducing or eliminating elder financial abuse. While the same wrongful conduct can create both civil and criminal liability, the legal requirements and the practical considerations of each differ significantly. Generally, civil lawyers are unaware of the requirements for a successful criminal prosecution; similarly, prosecutors are often unaware of the requirements for a successful civil action. both may be frustrated that the other lacks greater interest or insight. The purpose of this publication is to bridge this gap by providing an overview of the law, issues, and practical concerns of elder financial abuse from both a civil and criminal perspective. its goal is to promote understanding between prosecutors and victim’s lawyers with the expectation that this will lead to greater cooperation and thereby help reduce elder financial abuse

Hard copies available at the IOA tableDownload the PDF here: http://www.ioaging.org/File%20Library/Abuse/CivilCriminalResourceGuide_0512.pdf

The Journey Continues. We have grown as a team and we continue to re-evaluate our structure, and services, in an effort to improve outcomes for our clients.