Photo Courtesy of Alyssa L. Miller

An article in The Atlantic, published on January 6, 2015, highlighted several tragic stories of elder abuse and neglect in California that resulted from family caregivers receiving support from the publicly funded In-Home Supportive Services program (IHSS).

One case involved Yolanda Farrell, an 85-year-old former real-estate underwriter who loved to travel. Ms. Farrell’s daughter, Linda Raye, who was previously homeless, was hired as her mother’s official caregiver and collected $900 a month from California’s IHSS. Ms. Raye abused and neglected her mother who, as a result, eventually died.

IHSS’s mission is to allow adults with long term care needs (older as well as younger adults with disabilities) to direct their own care, by deciding who provides their home care and what type of care they receive. California’s IHSS program is part of Centers of Medicare & Medicaid Services’ (CMS) nationwide Cash & Counseling initiative, which has allowed states to implement these programs, each of which operates under a different name (i.e., in New York State the program is called Consumer Directed Personal Assistance Program). In many states, beneficiaries can choose between this program and other more traditional programs that utilize home health care agencies. Some states allow beneficiaries to appoint an agent, such as a power of attorney or guardian, to direct their care if they are unable to do so.

Cash & Counseling programs have fostered successful outcomes such as reducing long term care costs, allowing individuals who need assistance with their activities of daily living (ADLs) to have more control over their services, and reducing gaps in needed care. However, The Atlantic article highlights several program limitations that increase risk for elder abuse, neglect, and exploitation.

Four limitations that provide elder justice professionals with opportunities to provide resources and support to these programs and beneficiaries include:

• Cash & Counseling programs offer financial incentives for program enrollment providing opportunities for financial exploitation and neglect: External oversight for the care differs from state to state, and can sometimes consist of of infrequent home visits or check-ins by program administrators. Abusers thus can use this program to receive payment whether or not appropriate care is provided. ¹ Program directors can partner with elder justice professionals to identify resources that may help them to identify financial exploitation, make referrals to other programs and services, and link beneficiaries with resources that can help prevent financial exploitation from happening. In addition, elder justice professionals have experience with the complexities of power of attorney and guardianship oversight and may be able to help identify caregivers who may be financially exploiting the beneficiary and help guide the response to these complex cases.

• Paid caregivers receive limited training: Training requirements vary state to state, but are often limited.  In most states, training of the caregiver is the responsibility of the beneficiary and is meant to be one of the main ways they can control their care. However, a lack of training can lead to abuse, especially if the care recipients has dementia and/or other health care needs that can lead to behavioral problems and aggression. The elder justice field can help address this need by advocating for training for these care providers and highlighting existing programs that have a focus on abuse prevention.

• Care beneficiaries do not have protection from third party observers such as formal caregivers and/or home care agencies: Isolation is a risk factor for and consequence of elder abuse. Abusers often isolate older adults to perpetuate abuse and keep it hidden. Isolation can be reduced by encouraging program participants to attend community senior centers and by connecting them with programs that provide home visitation. Elder justice professionals can provide local Cash & Counseling programs with information and resources about available programs and services for older adults.

• Cash & Counseling programs lack screening for and response to abuse, neglect, and exploitation: There is currently little to no abuse screening or financial oversight for Cash & Counseling program beneficiaries. Program directors can partner with elder justice professionals who have expertise with developing screening tools and other safeguards for beneficiaries. It’s important that program directors are aware of available Multi-Disciplinary Team (MDT) case consultations. Cases will involve both financial and care dependency relationships and MDTs can be a resource for professionals who identify cases and need help navigating the many complexities involved with responding.

Cash & Counseling programs provide older adults with opportunities to maintain their autonomy and direct their care; however, there also several program limitations that have resulted in elder abuse, neglect and exploitation. We, as elder justice professionals, share the belief that older adults should live autonomously with dignity and well-being. Together we can partner with these programs to decrease risks, identify elder abuse cases, and help older adults live free from abuse and exploitation.

What are your thoughts about additional ways that the elder justice movement can impact these programs? Please share your thoughts in the comment section below.

By Elizabeth Bloemen, MPH, NYCEAC Social Media Associate and Cara Kenien, LMSW, MPA, NYCEAC Social Media Manager

1. New York’s regulations require that the person coordinating the medical care and the finances of the home care recipient not be the same person who is actually paid to provide care. For more information visit NY Health Access.