Elder Justice
Stronger Federal Leadership Could Help Improve Response to Elder Abuse Gao ID: GAO-11-384T March 2, 2011This testimony discusses ending elder abuse, neglect, and exploitation. Each day, news reports cite instances of older adults across the U.S. being abused and denied needed care, often by those they depend on the most. Neglect and abuse often go hand in hand with financial exploitation, which can rob older adults of the life savings and property they count on to support them in old age. In addition to the physical, psychological, and economic harm elder abuse inflicts on older adults, it can impose an economic burden on all Americans, increasing public expenditures on health care and the demand for a range of supportive services. A 2009 study estimated that 14.1 percent of non-institutionalized older adults nationwide had experienced some form of elder abuse in the past year. In all likelihood, this underestimated the full extent of elder abuse, however, because older adults who are highly cognitively impaired may be underrepresented in this study. States are primarily responsible for protecting older adults from abuse, neglect, and exploitation. In each state, an Adult Protective Services (APS) program aims to identify, investigate, resolve, and prevent such abuse. On the federal level, two statutes establish the government's role and responsibility with regard to elder justice in general--the Older Americans Act of 1965 (OAA) and the Elder Justice Act of 2009 (EJA). The OAA requires the Administration on Aging (AoA) in the Department of Health and Human Services (HHS) to administer formula grants to state agencies on aging for elder abuse awareness and prevention activities and lays out AoA's responsibilities to provide leadership, disseminate information, collect data, and support research in the elder justice area. The EJA authorizes funding for state APS programs and calls for federal leadership and coordination in the elder justice area. It also requires HHS, in conjunction with the Department of Justice (Justice), to disseminate best practices, provide technical assistance, collect data, and support research aimed at responding to elder abuse. Justice is also authorized to award grants to provide assistance to victims of abuse in general under the Victims of Crime Act of 1984 and of domestic violence under the Violence Against Women Act. These requirements are not specific to older adults, however. This statement is based on our report for this Committee, entitled "Elder Justice: Stronger Federal Leadership Could Enhance National Response to Elder Abuse," which is being issued today. It will cover (1) challenges state APS programs face in identifying, investigating, and resolving elder abuse cases, and (2) federal funding, activities, and leadership in the elder justice area.
Among the challenges facing state APS programs, states reported that their caseloads are growing. A number of APS officials told us that elder abuse reports and investigations have been increasing steadily over the past few years and over half the states reported that the size of their elder abuse caseload posed a very great or great challenge for them. In addition, several APS officials indicated that their cases were becoming more complex, and therefore more difficult to investigate and resolve. Cases more frequently involved multiple types of elder abuse, including financial exploitation; victims with diminished cognition; and/or substance abuse on the part of the victim or perpetrator. Moreover, states reported that funding for APS programs was not keeping pace with increases in the number and complexity of cases. APS program officials told us that, as a result, it was difficult to ensure adequate staffing levels, staff training, and public awareness activities. Federal elder justice activities, such as training, research, and providing guidance, have been scattered across eight agencies in two departments, HHS and Justice. Of the federal elder justice activities described above, only the AoA formula grants for prevention and public awareness of elder abuse could be used to fund APS operations from fiscal year 2005 through fiscal year 2009. Other activities may have indirectly supported APS during that time, but did not provide any direct funding for APS operations. In fiscal year 2009, federal agencies expended a total of $11.9 million on elder justice activities.
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United States Government Accountability Office:
GAO:
Testimony:
Before the Special Committee on Aging, U.S. Senate:
For Release on Delivery:
Expected at 2:00 p.m. EDT/EST:
Wednesday, March 2, 2011:
Elder Justice:
Stronger Federal Leadership Could Help Improve Response to Elder Abuse:
Statement of Kay E. Brown, Director:
Education, Workforce, and Income Security:
GAO-11-384T:
Mr. Chairman and Members of the Committee:
I am pleased to have the opportunity to participate in today's hearing
on ending elder abuse, neglect, and exploitation. Each day, news
reports cite instances of older adults across the U.S. being abused
and denied needed care, often by those they depend on the most.
Neglect and abuse often go hand in hand with financial exploitation,
which can rob older adults of the life savings and property they count
on to support them in old age. In addition to the physical,
psychological, and economic harm elder abuse[Footnote 1] inflicts on
older adults, it can impose an economic burden on all Americans,
increasing public expenditures on health care and the demand for a
range of supportive services. A 2009 study estimated that 14.1 percent
of non-institutionalized older adults nationwide had experienced some
form of elder abuse in the past year.[Footnote 2] In all likelihood,
this underestimated the full extent of elder abuse, however, because
older adults who are highly cognitively impaired may be
underrepresented in this study.
States are primarily responsible for protecting older adults from
abuse, neglect, and exploitation. In each state, an Adult Protective
Services (APS) program aims to identify, investigate, resolve, and
prevent such abuse.[Footnote 3] On the federal level, two statutes
establish the government's role and responsibility with regard to
elder justice[Footnote 4] in general--the Older Americans Act of 1965
[Footnote 5] (OAA) and the Elder Justice Act of 2009[Footnote 6]
(EJA). The OAA requires the Administration on Aging (AoA) in the
Department of Health and Human Services (HHS) to administer formula
grants to state agencies on aging for elder abuse awareness and
prevention activities and lays out AoA's responsibilities to provide
leadership, disseminate information, collect data, and support
research in the elder justice area.[Footnote 7] The EJA authorizes
funding for state APS programs and calls for federal leadership and
coordination in the elder justice area. It also requires HHS, in
conjunction with the Department of Justice (Justice), to disseminate
best practices, provide technical assistance, collect data, and
support research aimed at responding to elder abuse. Justice is also
authorized to award grants to provide assistance to victims of abuse
in general under the Victims of Crime Act of 1984[Footnote 8] and of
domestic violence under the Violence Against Women Act.[Footnote 9]
These requirements are not specific to older adults, however.
My remarks today are based on our report for this Committee, entitled
Elder Justice: Stronger Federal Leadership Could Enhance National
Response to Elder Abuse,[Footnote 10] which is being issued today.
They will cover (1) challenges state APS programs face in identifying,
investigating, and resolving elder abuse cases, and (2) federal
funding, activities, and leadership in the elder justice area.
Information and findings in our report are based on the results of our
2010 survey of APS programs in all 50 states and the District of
Columbia,[Footnote 11] visits to APS programs in California, Florida,
Georgia, Maryland, Texas, and Virginia, and interviews with APS
officials in the District of Columbia, Maine, and Pennsylvania. We
selected these states to achieve variation in their location,
administrative structure, and the size of their older adult
population. We also interviewed officials from HHS and Justice,
reviewed relevant federal laws and regulations, and analyzed federal
budgetary and other documents. Elder abuse experts and representatives
from organizations with an interest in elder justice issues provided
valuable information for this report.
We conducted our work from November 2009 through February 2011 in
accordance with generally accepted government auditing standards.
These standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
In summary, we found that state APS programs are facing considerable
challenges in responding to elder abuse. Many state APS programs are
facing growing caseloads and increasingly complex cases; dwindling
resources; insufficient information on effective practices and
interventions; difficulties collecting and maintaining case-level
data; and inadequate collaboration with law enforcement authorities,
prosecutors, and financial institutions. While there have been a
number of federal efforts to help states overcome these challenges,
they have fallen short of supporting APS programs in two key areas--
access to information on effective practices and interventions, and
access to uniform nationwide APS data. In addition, while the OAA
calls attention to the importance of federal leadership in the elder
justice area, this leadership is lacking.
Nationwide, State APS Programs Face Significant Challenges:
Among the challenges facing state APS programs, states reported that
their caseloads are growing. A number of APS officials told us that
elder abuse reports and investigations have been increasing steadily
over the past few years and over half the states reported that the
size of their elder abuse caseload posed a very great or great
challenge for them. In addition, several APS officials indicated that
their cases were becoming more complex, and therefore more difficult
to investigate and resolve. Cases more frequently involved multiple
types of elder abuse, including financial exploitation; victims with
diminished cognition; and/or substance abuse on the part of the victim
or perpetrator. Moreover, states reported that funding for APS
programs was not keeping pace with increases in the number and
complexity of cases. APS program officials told us that, as a result,
it was difficult to ensure adequate staffing levels, staff training,
and public awareness activities.
APS is primarily the responsibility of the states, and in 19 of the 28
states that could provide this information in our survey, more than
half of the APS budget in fiscal year 2009 came from state and local
revenues. In five states the entire APS budget came from these
sources.[Footnote 12] While no federal funding is currently dedicated
exclusively to APS programs, states have pulled from a number of
federal sources for funding. Social Services Block Grants (SSBG)
[Footnote 13] and Medicaid funds[Footnote 14] appear to be the largest
sources of federal funding for APS programs. Based on responses to our
survey, at least $206.2 million in SSBG funds and $42.3 million in
Medicaid funds were allocated to APS programs in fiscal year 2009.
[Footnote 15]
In addition, the limited availability of information on how best to
resolve elder abuse cases affects APS programs' ability to respond to
these cases. Nearly all states reported that APS programs would
benefit from additional guidance specifically tailored to APS needs.
Officials from two states told us that without access to information
on effective interventions, APS staff must repeatedly struggle to
develop their own solutions for resolving complex elder abuse cases.
In contrast, state Child Protective Services (CPS) programs have
access to several federally-funded resource centers where they can
find information on, for example, promising CPS practices and the
legal and judicial aspects of the child welfare system.
Some states also have difficulty collecting, maintaining, and
reporting their state-wide case-level data, which hampers their
ability to track outcomes and assess the effectiveness of services
provided. In addition, APS program officials and elder abuse experts
told us that APS programs would benefit from a national system for
collecting, maintaining, and disseminating uniform APS case-level
data. Access to data from such a system would enable APS program
officials to better understand programmatic trends, such as the
characteristics of populations in the state that are most vulnerable
to abuse and changes in caseload composition. Administrative data can
also provide information on the outcomes of interventions, which is an
important first step in determining their effectiveness. Currently, it
would be difficult to compile such data across states because the
types of case-level data APS programs collect, and the reliability of
these data, vary by state.
Finally, APS programs sometimes do not receive the support from law
enforcement authorities, prosecutors, and financial institutions they
need to effectively and efficiently resolve elder abuse cases,
according to program officials and experts. Law enforcement
authorities are faced with many competing demands on their time,
prosecutors may be unwilling or unable to prosecute elder abuse cases,
and concerns related to privacy may discourage financial institutions
from working with APS on cases of financial exploitation.
Federal Activities Have Provided Some Support to APS, but Federal
Leadership Is Lacking:
Federal elder justice activities, such as training, research, and
providing guidance,[Footnote 16] have been scattered across eight
agencies in two departments, HHS and Justice. Figure 1 shows the
departments and agencies that funded or implemented federal elder
justice activities from fiscal year 2005 through fiscal year 2009.
Figure 1: Federal Elder Justice Activities, Fiscal Years 2005 through
2009:
[Refer PDF for image: illustration]
Key Elder Justice Activities:
Training:
Office on Violence Against Women [DOJ}:
Grants for training for law enforcement, attorneys, judges, and others.
Office for Victims of Crimes [DOJ}:
Grants for training for law enforcement,attorneys, judges, and others.
Administration on Aging [HHS]:
National Center on Elder Abuse (NCEA) grants for online training.
Guidance:
National Institute of Justice [DOJ}:
Grants for research related to elder abuse.
National Institute on Aging [HHS]:
Grants for research related to elder abuse.
Administration on Aging [HHS]:
NCEA grants to collect and disseminate information on elder abuse.
Prevention:
Administration on Aging [HHS]:
NCEA grants to collect and disseminate information on elder abuse.
Administration on Aging [HHS]:
Formula grants to state agencies on aging for prevention and awareness.
Research:
National Institute of Justice [DOJ}:
Grants for research related to elder abuse.
National Institute on Aging [HHS]:
Grants for research related to elder abuse.
Collaboration:
Administration on Aging [HHS]:
NCEA grants for developing local multidisciplinary elder abuse teams.
Office for Victims of Crimes [DOJ}:
Grant for a manual on establishing multidisciplinary elder abuse
fatality review teams.
Civil Division [DOJ}:
Grant to identify barriers related to elder abuse prosecutions.
National Data Collection:
Centers for Disease Control and Prevention [HHS]:
Effort to develop common definitions of elder abuse.
Office of the Assistant Secretary for Planning and Evaluation [HHS]:
Grant to study the feasibility of establishing a national data
collection system for elder abuse.
Source: GAO analysis of elder justice activities based on interviews
with federal officials and related agency documents.
Note: Justice's Bureau of Justice Statistics and National Institute of
Justice also issued a grant in 2010 to compare administrative data on
elder abuse from a number of sources, including APS.
Note: Justice's Bureau of Justice Assistance also provided a grant in
fiscal year 2010 to develop and disseminate a pocket guide for those
working in state and local justice systems on legal issues related to
elder abuse. The guide will include topics such as powers of attorney,
financial exploitation, legal responsibilities of fiduciaries,
capacity issues, informed consent, and undue influence in elder abuse
cases. It is expected to be available in August 2011.
[End of figure]
Of the federal elder justice activities described above, only the AoA
formula grants for prevention and public awareness of elder abuse
could be used to fund APS operations from fiscal year 2005 through
fiscal year 2009.[Footnote 17] Other activities may have indirectly
supported APS during that time, but did not provide any direct funding
for APS operations.[Footnote 18]
In fiscal year 2009, federal agencies expended a total of $11.9
million on elder justice activities. Figure 2 shows federal sources of
funding in 2009 for elder justice activities and the amount from each
source.
Figure 2: Amount of Federal Funding Expended on Elder Justice
Activities in Fiscal Year 2009, by Department and Agency:
[Refer to PDF for image: illustration of differing sized circles]
Dept. of Health and Human Services ($7.0 million total):
Administration on Aging: $5.9 million;
National Institute on Aging: $1.1 million;
Centers for Disease Control and Prevention: $50,000.
Dept. of Justice ($4.9 million total):
Office on Violence Against Women: $3.1 million;
National Institute of Justice: $1.2 million[A];
Office for Victims of Crimes: $516,000;
Civil Division: $75,000.
Source: GAO analysis of federal funding for elder justice activities
based on agency documents and interviews with federal officials.
Note: Size of the circles in Figure 2 are proportional to amount of
funding by agency in fiscal year 2009. While the Office of the
Assistant Secretary for Planning and Evaluation completed elder
justice-related work in fiscal year 2009, funding for this work was
provided in fiscal year 2006.
[A] Of this amount, $650,000 came from the Civil Division's funding
for elder abuse research.
[B] The Civil Division also expended $361,000 in fiscal year 2009 for
hiring staff to provide legal and law enforcement support for cases of
elder abuse in institutions, although this was outside the scope of
our study.
[End of figure]
Federal elder justice activities have provided only some support for
APS programs to address their challenges. For example, AoA's National
Center on Elder Abuse (NCEA) provides access to a substantial amount
of information related to elder abuse on its website, but APS program
officials in five of the nine states we contacted told us that
relatively little of this information is tailored to their needs.
Specifically, the NCEA website includes a database of "promising"
practices on a very wide range of topics. However, AoA officials
stated that few of these practices are evidence-based,[Footnote 19] as
they have not been evaluated. Further, most states indicated in our
survey that these practices were of no more than moderate use to them.
AoA officials also noted that there is a lack of research establishing
APS evidence-based practices and interventions.
Although AoA has been required by law since 2006 to develop
objectives, priorities, policy, and a long-term plan for collecting
and reporting uniform state-level data on elder abuse, to the extent
practicable,[Footnote 20] its efforts to do so have been limited to
activities such as supporting a recent Centers for Disease Control and
Prevention effort to develop uniform definitions for elder abuse.
[Footnote 21] This effort may help lay the groundwork for a national
APS data collection system.[Footnote 22] In contrast, in the child
welfare area, HHS has worked with states to improve and compile state
administrative data, and hold annual technical assistance meetings to
review data collection, discuss challenges, and produce reports based
on case-level child welfare data.[Footnote 23]
To support collaboration among APS and its partners, such as law
enforcement, AoA has funded projects for developing community elder
justice coalitions. In addition, training sessions provided by
Justice's Office for Victims of Crimes and Office on Violence Against
Women have provided opportunities for law enforcement officers,
attorneys, judges, medical professionals, and APS staff to build
working relationships.
Although the OAA calls for federal leadership in the elder justice
field,[Footnote 24] we found that this leadership was lacking. Under
the OAA, AoA is the primary federal agency responsible for providing
national leadership in the elder justice area, but its efforts to do
so have been limited. A senior AoA official noted that AoA has helped
facilitate elder justice activities by participating in an informal
interagency workgroup that includes agencies within HHS, Justice, and
others that shares information on these activities. However, according
to AoA officials, this ad hoc group meets infrequently, has no formal
structure or charge, and produces no documentation of its meetings.
In addition, no national policy priorities currently exist in this
area, and multiple agencies' attempts to establish policy and research
priorities over the past decade have produced limited results.
Justice's Civil Division recently funded a grant with AoA and the
Office of the Assistant Secretary for Planning and Evaluation at HHS
to identify and prioritize elder justice policy, practice, and
research issues and develop recommendations to the government to
address those issues. This effort is expected to be completed by
January 2012.
The EJA reaffirmed the importance of federal leadership and provides a
vehicle for establishing and implementing national priorities in this
area. It mandates the creation of a federal Elder Justice Coordinating
Council, to include the Secretary of HHS, the Attorney General, and
heads of related federal offices.[Footnote 25] It also mandates the
creation of an Advisory Board on Elder Abuse, Neglect, and
Exploitation--made up of 27 members of the general public with elder
abuse expertise--to propose national elder justice priorities.
[Footnote 26]
In our report released today, we are making one recommendation that
HHS examine the feasibility and cost of providing APS programs access
to information on effective practices and interventions and three
recommendations to facilitate development of a system for collecting,
maintaining, and disseminating nationwide uniform APS case-level data.
Specifically, we are recommending that the Secretary of HHS:
* Determine the feasibility and cost of establishing a national
resource center for APS-dedicated information that is comprehensive
and easily accessible.
* Direct AoA to develop a comprehensive long-term plan for
implementing a nationwide data collection system within a reasonable
amount of time.
* Convene a group of state representatives, in coordination with the
Attorney General, to help determine what APS administrative data on
elder abuse cases would be most useful for all states and the federal
government to uniformly collect, and how a nationwide data collection
system should be designed.
* Conduct a pilot study, in coordination with the Attorney General, to
compile, collect, and disseminate APS administrative data.
We provided a draft of our report to HHS and Justice for review and
comment. With regard to our recommendations, HHS indicated it will
review and explore options for implementing them. Both HHS and Justice
provided technical comments that we incorporated into the report, as
appropriate.
Mr. Chairman, this concludes my statement. I would be pleased to
respond to any questions that you or any other Members of the
Committee may have.
GAO Contacts and Acknowledgments:
For questions about this statement, please contact Kay E. Brown at
(202) 512-7215 or brownke@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this statement. Individuals who made key contributions to this
statement include Divya Bali, James Bennett, Sue Bernstein, Clarita
Mrena, Nhi Nguyen, Eve Weisberg, and Craig Winslow.
[End of section]
Footnotes:
[1] In this document, we use "elder abuse" to refer to elder abuse,
neglect, and exploitation.
[2] Ron Acierno et al, "National Elder Mistreatment Study," a report
funded by the National Institute of Justice, U.S. Department of
Justice (2009). Although this study reports a combined one-year
prevalence figure of 11.4 percent, the estimate we provide also takes
into account the prevalence of financial exploitation found by this
study.
[3] Most of these programs also respond to alleged abuse of at-risk
adults in general, regardless of age.
[4] The Older Americans Act of 1965 defines elder justice as "efforts
to prevent, detect, treat, intervene in, and respond to elder abuse,
neglect, and exploitation and to protect older individuals with
diminished capacity while maximizing their autonomy; and the
recognition of the [older] individual's rights, including the right to
be free of abuse, neglect, and exploitation." 42 U.S.C. § 3002(17).
[5] Pub. L. No. 89-73, 79 Stat. 218 (codified as amended at 42 U.S.C.
§§ 3001-3058ff).
[6] Pub. L. No. 111-148, tit. VI, subtit. H, 124 Stat. 119, 782-804
(2010) (to be codified at 42 U.S.C. §§ 1320b-25, 1395i-3a, and 1397j-
1397m-5).
[7] 42 U.S.C. §§ 3058-3058ff.
[8] 42 U.S.C. § 10603(a)(2)(A).
[9] 42 U.S.C. § 3796gg(b).
[10] GAO, Elder Justice: Stronger Federal Leadership Could Enhance
National Response to Elder Abuse, [hyperlink,
http://www.gao.gov/products/GAO-11-208] (Washington, D.C.: Mar. 2,
2011).
[11] Survey questions and responses are presented in GAO-11-129SP, an
electronic supplement to the report.
[12] Twenty-two states were unable to provide complete funding
information for their APS programs by source in fiscal year 2009.
Thus, we were unable to determine the proportion of non-federal versus
federal funding for these states.
[13] HHS's Administration for Children and Families distributes SSBG
funds by statute to states in proportion to each state's population to
provide a wide range of social services best suited to the needs of
its residents. 42 U.S.C. §§ 1397-1397f.
[14] Medicaid funds can be used by states for costs such as personal
care services and targeted case management. In addition, the Social
Security Act authorizes HHS to provide 'Medicaid waivers' to states
that apply to allow them to spend federal Medicaid dollars on home-and
community-based services not traditionally covered under the Medicaid
program. 42 U.S.C. § 1396n(d).
[15] In fiscal year 2009, total SSBG funding to states was $1.7
billion. This amount does not include specific earmarks or
supplemental grants, such as for disasters. In fiscal year 2009, total
Medicaid funding was $215.6 billion.
[16] Federal elder justice activities can target elder abuse, as well
as health care fraud, consumer fraud, and civil rights violations
against older adults. This statement provides information on
activities specifically related to elder abuse.
[17] APS also competed with the broad range of other state programs
for SSBG funds received under Title XX of the Social Security Act, but
the SSBG is generally not viewed as an elder justice program. The EJA
established a separate grant program under Title XX specifically for
elder justice activities. 42 U.S.C. § 1397j.
[18] While by all accounts OAA formula grants are the sole source of
funds for elder justice activities directly available to APS, we did
not perform exhaustive legal research to determine if there are any
circumstances under which any other elder justice activities could
have resulted in funds going directly to APS in fiscal year 2005
through fiscal year 2009.
[19] The Centers for Disease Control and Prevention, AoA, and the
National Institute of Justice have all emphasized the importance of
using the best available evidence to develop a more effective response
to elder abuse.
[20] 42 U.S.C. § 3011(e)(2)(A)(iii) and (iv).
[21] This study is expected to be released in early 2011.
[22] AoA also provided information to HHS's Office of the Assistant
Secretary for Planning and Evaluation for a recently published report
on the feasibility of establishing a nationwide system for compiling
uniform APS data on elder abuse cases. The report noted several
factors to consider when creating such a system and noted ways to
strengthen existing APS data systems. Office of the Assistant
Secretary for Planning and Evaluation, Congressional Report on the
Feasibility of Establishing a Uniform National Database on Elder Abuse
(Washington, D.C.: March 2010).
[23] HHS developed the National Child Abuse and Neglect Data System to
collect such data from state CPS programs. States report data through
this system to the federal government, to the extent practicable, in
order to receive the Child Abuse Prevention and Treatment Act Basic
State Grant, which is available to all states to improve CPS systems.
[24] 42 U.S.C. § 3011(e)(2)(A)(ii).
[25] § 2021, 124 Stat. 786-87 (to be codified at 42 U.S.C. § 1397k).
[26] § 2022, 124 Stat. 787-89 (to be codified at 42 U.S.C. § 1397k-1).
[End of section]
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