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The opioid abuse crisis may be contributing to a ‘staggering’ spike in adult protective services caseloads. And local officials fear the problem will only get worse.
Five years ago, the vast majority of cases being investigated by Adult Protective Services agencies in places like Fairfield County, Ohio, which includes the far southeastern suburbs of Columbus and borders the state’s Appalachian region, could be categorized as neglect or self-neglect. These cases might involve hoarding behaviors on the part of older adults, seniors that are incapable of staying on top of critical medication routines, or an older person going without food or proper sanitation.
“Basically older people who were no longer able to take care of themselves or their own basic needs,” is how Janet Stout, a Fairfield County APS caseworker, described these cases. Fast forward to today, and Stout’s work looks very different. In the last five years, her county’s financial exploitation cases outnumbered their neglect cases—the first time that’s ever happened—and the instances of physical abuse are on the rise as well.
These cases are increasingly complicated and the costs to manage them are rising. The nationwide opioid epidemic is compunding the situation, and officials say that if more funding doesn’t come their way the problem will only get worse.
Kristi Burre is the deputy director of protective services in Fairfield County. Burre has been in that role for the past five years and said that even in that relatively short span of time “there have been some real drastic changes.”
According to Burre, Fairfield County is dealing with a dramatic increase in the sheer number of APS cases they’re being asked to investigate—a 75 percent increase in the last three years alone. Mindy VanBibber, the APS supervisor in Fairfield County, told Route Fifty that while each caseworker might have once been responsible for 10 or so cases at a particular moment, members of her staff of three are now each juggling 19 or 20 cases at a time.
Advocates and officials in other Ohio counties say their data tell a similar story.
Sara J. Junk, the social services supervisor in Pike County, a smaller, mostly rural county about 65 miles south of Columbus—who also serves as the chair of the Ohio Coalition for Adult Protective Services, a statewide group that strives to enhance the provision of services to at-risk adults—has seen a spike in her county’s caseload as well.
“In 2006 and 2007 we were running approximately 50 APS referrals. In 2016 we had 129, so it’s more than doubled, and we’re on target to do even more this calendar year,” Junk told Route Fifty in an interview in late August of 2017.
The caseload changes that Ohio officials report aren’t just happening in the Buckeye State. Elder abuse has become such a prominent issue that National Association of Attorneys General President and Kansas Attorney General Derek Schmidt announced that his term would focus on strengthening efforts nationwide to combat it, calling it “the silent epidemic of our time.”
In Schmidt’s release announcing the initiative, he claimed, “the numbers are staggering,” and, where numbers are available, they certainly reveal a growing problem. In 2016, The Boston Globe reported that since 2011, elder abuse reports had climbed 37 percent in Massachusetts, with more than 1,000 additional cases reported each year to protective services offices throughout the state.
Officials in Ohio and elsewhere are also quick to note that the data do not even come close to painting a complete picture. The accepted wisdom in the world of adult protective services is that only about 1 in 14 cases of elder abuse is reported to authorities. That means many more elderly people are likely suffering in silence.
And, Burre and Junk say, it’s not just the number of cases that is different as of the last few years.
“The abuse is on the rise, the [financial] exploitation is skyrocketing and neglect and self-neglect are on the lower ends of our referrals that we get,” said Junk of the situation in Pike County.
Taken as individual cases, stories of financial exploitation of the elderly are heartbreaking. APS caseworkers have seen seniors with their entire life savings wiped out, forced to leave their homes and left with few options. VanBibber, the Fairfield County caseworker, offered up the basic storyline of a financial exploitation case she was working on in August 2017: a grandchild convinced his grandmother that she needed him to help with her finances. She added him to her bank account, “and now we’re dealing with the aftermath of upwards of $23,000 missing,” said VanBibber.
But, when you consider the monetary losses associated with elder financial abuse across the county, the impact becomes even harder to fathom. In 2015, TrueLink Financial, a private financial services company, found that previous estimates of the problem were about 15 times too low. That 2015 report showed that across the country seniors lose roughly $36.5 billion each year to financial exploitation.
This is a problem with serious consequences. Truelink estimates that as many as 945,000 seniors are currently skipping meals as a result of financial abuse. According to the National Adult Protective Services Association, almost 1 in 10 seniors will wind up reliant on Medicaid as a direct result of their bank accounts being drained. And, NAPSA estimates that reporting levels are even lower for financial exploitation than they are for other types of elder abuse. Only one in 44 cases of financial abuse is ever reported.
Officials in Ohio don’t have a simple answer for why they’re seeing a spike in the number of cases and why those cases are different than they were before. While they can’t conclusively prove causation, many say they believe the rise in these types of cases and the increasing intensity of the state’s opioid epidemic are linked.
Where Do Opioids Fit In?
In order for the full picture of the possible connection between opioids and elder abuse to come into focus, it’s important to understand that, for the most part, the perpetrators of these types of abuse are not strangers to the victims.
Eight-five percent of the APS cases Fairfield County investigates involve family members taking advantage of, neglecting or abusing family members. And, the other common through-line that connects many of the cases Burre sees is substance abuse. Many of these cases involve an adult struggling with a drug addiction who moves back in with a parent or grandparent.
According to data in Fairfield County, 65 percent of the cases they investigate involve substance abuse and mental illness. In Pike County, Junk said her data reveal that these issues show up somewhere in the investigation storyline about 75 percent of the time.
A senior can become a target of substance-related abuse or exploitation in a number of ways. First as a source of money—Junk was quick to note that “everyone knows when the Social Security checks go out.”
She added that it “ would probably blow our minds how much money is being taken from the elderly just to support a drug habit.”
Secondly, elderly people become targets because of their access to opioid painkiller prescriptions. As an example, Burre brought up an elderly couple she had been working with who she said had been “sleeping with their prescriptions in their bra at night and under their pillow because their adult kids are living in the house and trying to steal their meds.” Burre said she’s seen elderly adults in need of palliative care because of cancer or a similarly agonizing disease who are forced to suffer the full brunt of their pain because they’re being robbed of crucial medication.
And, these county officials say they have seen elderly adults face physical abuse when a family member is so changed by their addiction that they become violent.
“With these types of substances, it’s hitting all socio-economic statuses. To these elderly customers, this is like their cherished grandchild who they cook dinner for every Sunday night, and they truly are a changed person,” Burre said. “Their entire being is completely different because of a drug like this. We’re not dealing with functional adult grandchildren and kids who are visiting grandma and grandpa or taking care of them,” she added.
Burre acknowledges that, to some extent, addiction has always been a factor in the work of protective services agencies.
“Substance abuse on our caseload is not a new concept,” she said. But “this is different. Even five years ago we weren’t experiencing what we’re experiencing now with these types of substances.”
Junk put it this way: “It’s almost astronomical the way the opioid crisis has affected the elderly people.”
The APS cases that have come out of that crisis are incredibly challenging to handle. In prior years, the bulk of the cases that and APS agency might investigate only required what Burre called “information and referral work.” Such cases could be handled over the phone or even with just one home visit where a caseworker worked one-on-one with the elderly customer. But, Burre said, “that type of practice and that approach does not work with these [new] types of cases.”
“If that ever really worked in the past,” she added, “it definitely does not work today with everything we’re dealing with.”
It’s ‘Horribly Complicated’
Adult Protective Services casework isn’t the kind of job everyone can do. In conversations with these Ohio officials, the refrain that surfaced over and over again is that it takes a certain type of heart to do this kind of work.
“I believe everybody is called to something,” said Junk. “I’ve always had this draw toward elderly people.”
Stout, the Fairfield caseworker who has been working in APS for 11 years, said she came to the job because she “grew to have a heart for older people.”
But having that heart also means that often, the job is just plain hard.
“We can close our office door and vent to one another when we’re frustrated. We even cry at times,” Stout said of her and her fellow caseworkers’ reaction to the stress of the job. “Because we do see some very sad situations.”
And besides being, at times, a deeply emotionally taxing job, the work of APS is also getting much more logistically involved.
Part of what makes APS investigations challenging is that are completely voluntary on the part of the victim. An older adult has to consent to being helped by caseworkers like Janet Stout in Fairfield County. If an elderly person refuses services, in many cases, APS workers have to wash their hands of their case.
That means that oftentimes an older person has to be convinced that it’s in their best interest to cooperate with caseworkers. Older people are often afraid that if they consent to an APS investigation it could lead to them losing their independence, leaving their home and being forced to move to a facility like a nursing home—although APS workers say steps like these are only taken when there is no other option. In many ways, the job of APS caseworker has parallels with the roles of people who help victims of domestic violence.
“It takes a different level of trust that you have to build with them,” said Burre. And, building that trust takes time, patience and finesse.
Burre and Junk both said that in Fairfield and Pike counties, the fact that opioid issues have become increasingly interwoven with their APS work makes this part of their investigations much more difficult.
“When you have relatives that become manipulative because of their own addictions and their own hidden agendas it becomes even more difficult to work with the elderly adults than it has in the past,” said Burre. “They’re becoming trickier cases to manage and work with.”
“Horribly complicated,” is how Junk put it.
These cases require much more in-depth involvement from case workers and at times from law enforcement.
Detective Bryan Underwood, who works alongside Fairfield County’s APS workers as a representative of the city of Lancaster’s police department, said he often sees relatives in the victim’s home actively encouraging the elderly person to resist cooperating with the APS investigation. And Burre said that many of these older adults lack a complete understanding of just how serious the substance abuse problems of their relatives.
“Some of the elderly, they’re so in shock, they’re in denial, they don’t understand. They don’t understand the drug, they don’t understand how much of an impact it’s having.”
Stout, the Fairfield County APS caseworker, remembers one investigation particularly vividly: an 82 year-old woman who had been emotionally, financially and physically abused by her great grandson—he broke into her home when she told him he could no longer stay with her and at one point grabbed her throat and twisted her arm, threatening to break it.
In this situation, Stout said, the elderly woman eventually “did come to the realization that her great-grandson had been doing drugs because she had found the paraphernalia when she was doing laundry. So she did know that on some level.”
But Stout added that the woman’s “grandmotherly heart overrode any concerns she had.” When Fairfield County APS closed the case, the young man was in a treatment facility and his great-grandmother was still making plans for him to return to her home because, according to Stout, “she wants to be sure he has a place to live and that he’s safe and that he has a home-cooked meal.” It’s what many great-grandmothers might do. But, Fairfield County’s APS workers know that it’s not in the interest of the health and safety of the older woman.
The changing nature of these cases has meant that APS departments are having to develop closer relationships with financial institutions—working with banks to be sure that suspicious activity can be properly investigated to rule out financial exploitation—and with the court system. In the past, it was relatively rare for these agencies to declare older people legally incompetent, but those cases are increasing as well. Junk said that years ago, they would take maybe one or two cases to probate court per year. Now they’re doing an average of 10.
And all this costs money.
'The Bottom of the Barrel'
For all the ways in which the stories of Fairfield and Pike Counties run parallel to one another, they differ in one crucial respect—funding.
Fairfield County supplements its Adult Protective Services budget with a local levy, meaning that more than 65 percent of their overall funding comes from local sources. In Pike County, no such levy exists. That means Junk and her colleagues are completely reliant on the funding they get from the state.
As of 2016, the amount available for protecting the elderly in all of Ohio was $2.64 million—which comes out to just $30,000 per county. And, it should be noted that, incredibly, that $30,000 is an enormous improvement from what the state provided before.
Historically, Ohio has spent very little on adult protective services.
“We’ve done the bottom of the barrel as far as serving the elderly and we have historically been the bottom of the barrel in terms of our investment in Ohio’s elderly,” said Junk.
State law in Ohio mandates that each county is responsible for investigating reports of suspected abuse. But before 2016, annual allocations for adult protective services were as low as $500,000—for the entire state. And, the money wasn’t doled out equally. In 2015, the adult protective services agency in a county like Monroe County for example, a jurisdiction on the eastern border of the state just across the Ohio River from West Virginia, received as little as $852. And that wasn’t even the bottom—there were counties that received as little as $500.
“At one point,” Junk from Pike County recalled, “I was getting about $1,000. I had 4,400 elderly people to protect and I got $1,000 to do that for the whole year.”
Burre said that in 2014 and 2015 her county received about $5,000 from the state for mandated services.
So compared with that, $30,000 a year seems great. But, while Burre and Junk say they’re grateful for the increase, which was proposed by Gov. John Kasich, they also say that the amount doesn’t even approach what they actually need.
The $30,000 is “not even close to being enough,” according to Junk. “That doesn’t even pay for one worker full-time when you think of the benefits, and the vehicle and the gas and the insurance.”
In Fairfield County, “from a budgetary perspective,” Burre said, “our cost associated with delivering adult protective services is around $500,000.” To make up the enormous difference between the money her agency gets from the state and their actual need, Fairfield County supplements their budget with their levy. In November, Fairfield County residents voted overwhelmingly to renew that levy for 10 years, with an increase. Burre said she frankly doesn’t know how she’d care for the elderly she serves without that extra money.
But, that kind of levy isn’t a viable option for every Ohio county. “You’re hard-pressed to get a levy passed in a county like mine,” said Junk, who noted that while her county does have one senior-focused levy, APS sees none of it. All of the money raised goes to the local senior center.
“Even our health department has tried on the last, oh I can’t even tell you how many ballots, [to get a levy approved] and they’re down to skeleton crew because we can’t get a levy passed,” Junk said.
As far as APS goes, Junk said she’ll gladly take that $30,000, but noted that “it would probably cost close to $250,000 just to meet our expenses in little Pike County.” And the way the situation is changing, little by little increases in state allocations just aren’t enough to really tackle what these caseworkers are seeing, particularly when the impact from the opioid epidemic is taken into consideration.
“If we have to crawl up the financial ladder on the state budget—you know, one and two million dollars at a time...,” Junk said. “We’re not even advancing fast enough in resources to keep up with the increase in the abuse and use. [The epidemic is] always going a mile faster an hour than we are and we are never going to catch up to it.”
And, these county officials say that at the federal level, there’s virtually no funding and nowhere to turn. Unlike Child Protective Services, there is no dedicated stream of federal dollars for APS. And, in 2010, when a comparison of Child Protective Services funding and Adult Protective Services funding was last conducted, the average spending per individual child under CPS was $45.03 compared with $3.90 per adult.
“I go on Grants.gov and I’m digging through all this stuff,” said Junk.” “I’m trying to find things and there’s nothing out there.”
Both Burre and Junk know that their situation is bound to get worse.
“The baby boomer generation is now going to continue to overtake our caseloads just by sheer population,” said Burre. “Right now, one in eight of our citizens are elderly and it’s going to be like one in five in the next five years,” she added. “The increases we see now are going to continue.”
“There are more and more counties in our state that are not going to be able to continue handling the need at the pace we’re going.”
Quinn Libson is a Staff Correspondent for Government Executive’s Route Fifty and is based in Washington, D.C.
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