The Critical Role of the Specialized Social Worker as Part of ED/Hospital-Based Elder Mistreatment Response Teams

Abstract

The emergency department and hospital provide a unique and important opportunity to identify elder mistreatment and offer intervention. To help manage these complex cases, multi-disciplinary response teams have been launched. In developing these teams, it quickly became clear that social workers play a critical role in responding to elder mistreatment. Their unique skillset allows them to establish close connections with community resources, collaborate with various hospital stakeholders, support patients/families/caregivers through challenging situations, navigate the legal and protective systems, and balance patient safety and quality of life in disposition decision-making. The role of the social worker on these multi-faceted teams includes: conducting a comprehensive biopsychosocial assessment, helping to develop a safe discharge plan, and making appropriate referrals, among other responsibilities. Any institution considering developing a multi-disciplinary program should recognize the critical importance of social work.

Introduction

Identifying and addressing socio-medical issues is a critical component of providing healthcare in the acute setting, particularly for older adults (Elman, 2021). Social workers have expertise in managing these complex challenges, including balancing patient goals and harm reduction when considering transitions of care and connecting patients to appropriate resources in the community. The value of social workers as part of the multi-disciplinary care team, particularly in the emergency department (ED), has been increasingly appreciated (Auerbach & Mason, 2010; Hamilton et al., 2015). Many EDs and hospitals have recognized this and added social workers to their staff, with some having 24/7 coverage.

Elder mistreatment (EM) is a sociomedical issue that can have a profound impact on an older adult patient’s health and quality of life (Lachs & Pillemer, 2015). EM may include physical abuse, sexual abuse, neglect, verbal/emotional/psychological abuse, and financial exploitation, with many older adults experiencing polyvictimization (Acierno et al., 2010; Lifespan of Greater Rochester, 2012; National Research Council, 2003). This mistreatment is common, with 10% of community-dwelling older adults and more than 20% of those living in facilities experiencing it each year (Acierno et al., 2010; Lachs & Pillemer, 2004; Lifespan of Greater Rochester, 2012). Exposure to EM increases risk of depression and can exacerbate progressing dementia (Dyer et al., 2000; Lachs & Pillemer, 2015). Despite this, EM is dramatically under-recognized, with as few as 1 in 24 cases reported to the authorities (Lifespan of Greater Rochester, 2012). The ED/hospital is an important opportunity to identify cases of EM and initiate intervention, as an encounter for an acute health issue may be the only time that an older adult experiencing EM ever leaves their home.

Whenever EM is identified or suspected in an ED or hospital, medical providers typically rely on social workers to take the lead in evaluation and intervention. Despite this, many ED and hospital-based social workers lack training for or confidence with assessment of EM (Felton & Polowy, 2015). Often, social workers have limited knowledge of EM, as few master’s programs include exposure to it as part of the curriculum (Policastro & Payne, 2014). Therefore, many ED and hospital social workers are unsure how to approach EM and have little guidance to support them. In addition, many physicians are equally, if not more, ill-equipped to support their social work colleagues in these interventions.

Given these challenges, interdisciplinary response teams were developed to assist in the management of older adult patients experiencing EM, similar to those that already exist to address child abuse and intimate partner violence. Child protection teams, which are present in most hospitals, consider having at least one social worker to be the standard of care (Hanson & Hill, 2012). Modeled in part on these teams, the first-of-its-kind, ED-based Vulnerable Elder Protection Team (VEPT) was launched in 2017 at Weill Cornell Medicine / NewYork-Presbyterian Hospital (WCM/NYP). In 2021, the University of Colorado, an international leader in child abuse pediatrics, launched the Vulnerable Elder Services, Protection, and Advocacy (VESPA) program, similar to VEPT. Both include specialized social workers as core team members and leaders.

Starting in 2021, the teams, members of which have been collaborating since 2013, conducted an annual 2-day in-person meeting to learn from each other and provide support for this difficult work. The critical role of the specialized social worker on these teams was a key topic of discussion at the second of these meetings / consensus conferences, which was conducted in New York City on the Weill Cornell campus from September 28–29, 2022.¹ In addition to both teams, attendees included ED and hospital social workers and leadership from the New York City Elder Abuse Center (NYCEAC). This article describes in detail the substance of the consensus reached after conversations about the specialized social worker’s role.

Recognizing the Value of a Specialized Social Worker

Social workers provide valuable knowledge and contributions to a response team, including using their skills in active listening, developing relationships, organizing, and synthesizing information while conveying messages to others on their level. Ms. Elman, a social worker, joined VEPT three months before the program launched. In addition to her administrative role, she engaged in several activities to develop her expertise. She compiled a comprehensive resource guide of local resources and services in 9 categories (e.g. dementia support, law enforcement/orders of protection, and case management) that may be relevant for older adults experiencing EM. She created this based on meeting with members of NYCEAC, discussions with experienced ED/hospital social workers, and extensive online research. Ms. Elman also spent time shadowing social workers in the ED and hospital as well as emergency physicians and hospital-based geriatricians. She attended NYCEAC multi-disciplinary team (MDT) meetings as well, which are held regularly in each New York City borough and bring together professionals from disciplines including: social services, medicine, law enforcement, and criminal justice to discuss challenging EM cases. By attending, Ms. Elman learned how EM cases were managed in the community and made valuable in-person connections to community-based professionals. She also read academic literature and book chapters about EM management and met with leading experts in EM, several of whom were serving as advisors to VEPT.

Ms. Elman participated in VEPT consultations in the ED from the time of the program’s launch, collaborating with both the VEPT on-call medical providers conducting forensic examinations and with the ED social workers. As she worked regular business hours, her evaluation occurred as part of the initial response if the team is activated during a weekday and often the next morning if the consult was overnight. Soon after VEPT launched, the value of having a social worker as part of VEPT became clear. Ms. Elman already had a close connection to Adult Protective Services (APS), which facilitated: obtaining collateral, ensuring community follow up after discharge, and coordinating a response strategy. Also, her connection streamlined referrals from the ED to APS and ensured that necessary information was included and APS eligibility was considered. Her knowledge of available community-based resources and how to quickly access them assured that older adults would be offered all appropriate referrals and receive needed services. Her strong relationship with community-based MDTs allowed her to bring challenging ED cases for discussion at team meetings to optimize management plans. Her connection to law enforcement and familiarity with the potential role of the justice system allowed her to advise patients and families about what to expect from this process, to report on their behalf, and to advocate for them.

Through managing many of these cases during the first several months after launch, she developed other relationships, experience, and skills that were critical. This included a collaborative relationship with the ED/hospital ethics and legal departments who were often involved in issues surrounding decision-making capacity. Also, she developed skills working with and supporting vulnerable older adults, who may have cognitive impairment, and gained extensive experience balancing safety and quality of life for patients in disposition decisions. Ultimately, she recognized the potential to prevent repeat hospitalizations if safety and medical concerns are adequately addressed. Reasons to have a specialized elder mistreatment ED/hospital-based social worker are summarized in Table 1.

Table 1:

Key Reasons to Have a Specialized Elder Mistreatment Emergency Department / Hospital-Based Social Worker

Establish close connection to APS, which can help with: • Obtaining collateral • Ensuring community follow-up • Coordinating a response strategy • Smoothing the referral process

Deep knowledge of available community-based resources and how to quickly access them

Strong relationship with community-based multi-disciplinary teams (MDTs)

Connection to law enforcement and familiarity with potential role for the justice system, including obtaining orders of protection and connection to victims’ advocates

Collaborative relationship with hospital ethics and legal teams

Skills supporting vulnerable older adults, including those who have cognitive impairment

Skill in supporting family members, including potential abusers, in the care of the older adult and ongoing investigation

Experience balancing safety and quality of life in disposition decision-making

Potential to prevent repeat hospitalizations if safety and medical concerns are adequately addressed

Connection to providers across the health care system, including connection to primary care medical homes to ensure patient needs are addressed when they leave the hospital

Though the initial plan had been for VEPT to rely heavily on collaboration with ED social workers, Ms. Elman’s role, given her special expertise, quickly grew. VEPT discovered that even experienced ED social workers knew little about how to manage these complex cases and deferred to Ms. Elman. Additionally, ED social workers were already very busy managing other patients and so were relieved that Ms. Elman took the lead on the time-consuming assessment and management of these older adults. That ED social workers represented the source of 26% of the VEPT consultations during the three years after program launch demonstrates this. Soon, when information about the VEPT program and Ms. Elman’s role became more widely known, social workers throughout the NYP health system began reaching out to discuss patients in their care who were experiencing EM. Though VEPT initially did not plan to provide any follow-ups after the initial ED-based consultation, many patients evaluated by VEPT were admitted to the hospital. Because of Ms. Elman’s unique expertise and the complexity of supporting and providing care to older adults experiencing EM, inpatient hospital medical teams and social workers frequently contacted her to provide additional follow-up consultations on hospitalized patients for days or even weeks after the initial assessment in the ED. Also, inpatient providers would reach out to her when potential EM was not initially suspected in the ED but later detected after hospital admission. With funding from the New York State Office of Victim Services (OVS), VEPT expanded to formally follow cases throughout the hospitalization and to provide initial consultations after hospital admission. As part of this expansion, a second VEPT social worker was recruited and hired.

VESPA Prioritizes Recruitment of a Social Worker

The VESPA team at the University of Colorado was modeled on the VEPT program as well as the Kempe Center for Child Abuse Child Advocacy Team at Children’s Hospital Colorado, which has social work leadership at its core. Based on these models, the core of the team’s initial grant funding was focused on providing a dedicated social worker for EM to serve emergency department and inpatient teams. The team was fortunate to recruit Sarah Cox, an author of this manuscript, who had limited experience with EM but brought substantial expertise and experience in older adult mental health and case management to the VESPA team. In addition to the duties and services outlined above, Ms. Cox has used her experience to help support not only the patient but also their loved ones navigate this complex system, providing ongoing bereavement and trauma informed support for patients and families until they are connected to further care. In addition, these cases can be distressing for medical providers involved, especially when there is a death in the hospital. Ms. Cox has led outreach to these providers and often provides necessary debriefings with medical teams about challenging cases. She is frequently sought after by the social work and case management department in the hospital system and is a key partner with our ethics team who seek her advice. The VESPA model provides social work follow up while the patient is in the hospital and until they have been reconnected to their primary care medical home. After several years on the team she has similarly developed close relationships with APS, law enforcement, victim’s advocates and other community providers often helping to expedite discharge for our most challenging cases.

Recognizing the Value of a Social Worker on an Elder Mistreatment Response Team

Given the breadth of their training and skillset, the social worker on the ED/hospital-based EM response team can have a multi-faceted role, summarized in Table 2. This includes performing a comprehensive biopsychosocial assessment, which often involves interaction and collaboration with the patient, their family and friends, outpatient medical providers, and community agencies to obtain important collateral. Through their conversations, the EM social worker can provide supportive and trauma-informed counseling to the patient and involved others. Utilizing a trauma informed lens provides an opportunity for the clinician and patient to acknowledge how traumas across the lifespan can impact the current abuse (Ernst & Maschi, 2018). SAMHSA purports that trauma-informed practitioners and programs abide by 6 principles: (1) recognize that some interventions may cause trauma or re-traumatization (2) provide training about trauma and re-traumatization (3) value the survivor’s voice (4) include the survivor’s perspective on appropriate interventions (5) recognize the importance of the person as a whole in the context of their environment (6) emphasize what the survivor has endured, not what may be “wrong” with them. The social workers on EM response teams try to employ these practices whenever possible to best serve these patients and empower them to actively participate in their discharge planning (Substance Abuse and Mental Health Services Administration, 2014). In addition, VESPA focuses on providing trauma informed care to the entire family system. Given their close connection with the child advocacy team and forensic nurses they will provide connection to resources for other family members and try to help ensure that all victims of maltreatment in a family system are recognized and provided services. This family focused approach is a cornerstone of their practice (Tiyyagura et al., 2020). Core practices of the social work profession such as practicing active listening, maintaining a judgement-free environment, and recognizing the worth of all individuals help make challenging discussions more successful and are especially important when working with alleged perpetrators. Remembering to meet the patient and family where they are and customizing interventions and safety plans to meet the goals of the patient are crucial responsibilities as well.

Table 2:

Core Responsibilities of the Specialized Elder Mistreatment Emergency Department / Hospital-Based Social Worker

Complete a comprehensive biopsychosocial assessment

Liaise with family, friends, outpatient medical providers, and community agencies resources to obtain collateral

Provide supportive counseling to the patient and involved caregivers / family

Evaluate for and address any immediate safety concerns, which may include organizing visitor restriction, patient name change, or security / safety watch

Coordinate communication between various members of the care team within the hospital (e.g.: primary medical team, social work, other consultants, ethics, legal, administration)

Help to develop a safer discharge plan

Make appropriate community referrals

Provide supportive counseling and resources to the patient and family

Facilitate the report of mistreatment to the appropriate authorities including APS, law enforcement, and the district attorney’s office

Provide handoff about pertinent safety concerns to primary care medical homes, subacute rehabilitation centers, or long-term care facilities as appropriate

Develop a strong therapeutic alliance and advocate for patient’s best interests, working to honor their wishes, when possible

Follow up with patients and families in the community after ED/hospital discharge

The role of the EM social worker also includes evaluating for and addressing any immediate safety concerns, which may include organizing visitor restriction, temporarily changing patient names in the electronic health record, making charts confidential to limit access through online portals, or facilitating a security / safety watch. The specialized social worker coordinates communication between various members of the care team within the hospital (e.g.: primary medical team, social work, other consultants, ethics, legal, administration) and are often a key source of continuity between rotating medical teams. They can help to develop a safe discharge plan, make appropriate community referrals, and facilitate the report of abuse to the appropriate authorities including APS, law enforcement, and the district attorney’s office. If concerned about the care provided at a facility, the social worker may make a report to the Department of Health. However, it is important to note that the EM social workers are not investigators, nor do they fulfill the role of law enforcement. While they do document signs of possible mistreatment and gather information that may assist police or APS in their investigation, their primary goal is to support the patient and family’s needs. The EM social worker may provide handoff about pertinent safety concerns to long-term care and rehabilitation facilities when appropriate. They can also follow up with patients in the community after ED/hospital discharge to ensure that an older adult and family are able to access desired resources and services and help them seek further care when appropriate. Throughout their work, the specialized social worker establishes a strong therapeutic alliance with the patient and family, advocates for patient’s best interests, and works to honor the patients’ wishes whenever possible.

The specialized social workers, while heavily involved in the care of the patient, do not replace the role of the primary team’s social worker or care manager. The focus of the EM-trained social worker is on addressing mistreatment-related concerns and supporting the medical team social worker. The primary social worker typically still makes referrals unrelated to mistreatment and secures homecare or facilitates finding a bed in a rehabilitation or skilled nursing facility. As the mistreatment-related work can be complex and time-consuming, the effort of the EM-trained social worker frees up the primary team’s social worker / care manager to focus on other aspects of their work and their other patients.

Multi-disciplinary teams similar to VEPT and VESPA have the potential to dramatically improve ED/hospital care for older adults experiencing EM, and specialized social workers are indispensable members of these teams. Even social workers with little previous experience in EM can develop expertise after joining these teams, focusing on the unique needs of this patient population and working closely with local community-based EM professionals. To support social workers on these teams, social workers from both VEPT and VESPA are committed to providing comprehensive documentation of their role as well as in-person and remote technical assistance.

Future Directions for Social Work-Focused Elder Mistreatment Response

Developing and maintaining a multi-disciplinary, on-call EM response team including medical providers is resource-intensive and may not be feasible or practical at smaller EDs/hospitals and those with few resources. Though a team comprised of various disciplines is ideal, under these circumstances, a social work program to help optimize care for patients with EM that can then consult medical providers as needed may be a consideration. One potential approach is to train an interested ED/hospital social worker to serve as a local champion. This champion could develop expertise and relationships with community-based EM professionals and then help guide the care of patients experiencing EM. Similar champion programs for nurses have been highly successful in improving palliative care and other focused areas (Kamal et al., 2019). However, it is important to note that, especially in the beginning, a medical provider / social worker partnership could be beneficial. The multi-disciplinary approach can help add clout to the program and further establish the social worker as an expert in EM. Jointly assessing patients experiencing EM, at least initially, may build more trust and buy-in from medical teams and administrators.

Telehealth may also offer an opportunity in the future for specialized social workers to contribute to care of older adults experiencing EM. The growth of the use of telehealth to delivery sub-specialty care in the ED/hospital in areas such as stroke, neurology, and psychiatry, already common in small and rural hospitals, accelerated during the COVID-19 pandemic. Social workers with expertise may deliver provider-to-provider and/or provider-to-patient tele-social work to offer expertise assessing and managing these patients.

A promising alternative approach currently being developed in one locale is having Area Agencies on Aging or APS embed one of their social workers in an ED/hospital to evaluate older adults experiencing EM and connect them to services.

While any specialized ED/hospital-based social work response to EM may improve care and outcomes for these vulnerable older adults, demonstrating impact on metrics important to the ED/hospital and health system is critical to encourage adoption. Therefore, future research should explore effects on length of stay, readmission, ED bounce-backs, and cost of care.

Improving Elder Mistreatment Education and Training for All Social Workers

In addition to increasing access to social workers with specialized knowledge about EM, ideally all social workers in the ED/hospital setting will be better trained to assess and manage these cases. EM should be integrated into Master’s-level social work curricula and continuing education modules should be created to offer training to social workers already in practice. Also, training should be incorporated into hospital onboarding and regular re-trainings. Notably, recognizing that ED social workers may need to take the lead in assessment and intervention in EM despite minimal education and training, a group including two of the authors of this manuscript (AE, TR) created the Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS). The ED-EMATS is a tool for social workers designed specifically for use in the ED to increase their confidence and ensure standardization between professionals (Elman et al., 2020). Tools similar to this could be developed for inpatient and outpatient providers and provide a promising way to improve care for this population.

Conclusion

A specialized social worker plays a critical role in existing ED/hospital-based EM response teams with multiple core responsibilities. Any institution or health system considering developing or launching a similar multi-disciplinary program should recognize the importance of social work. Additionally, other opportunities exist to increase access to specialized social work. Ultimately, all professional social workers in EDs/hospitals should receive additional education and training in EM to optimize care for these patients.

Supplementary Material

Supplementary Material

Online Supplementary Figure 1: Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS)—Initial Assessment

Online Supplementary Figure 2: Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS)—Comprehensive Evaluation

Data Availability Statement:

There is no available data to share.