TABLE 2.

Stakeholders Likely to Benefit from Nursing Home Elder Abuse Shelters: Relevant Domains for Evaluation and Potential Concerns

Stakeholder	Merits/Metrics	Concerns
Victims	Aversion of mortality and injury, improved depression and anxiety, treatment of unaddressed medical conditions, improvement in functional status. Safety. Reduction of risk. Civil, legal, and housing outcomes. Cost per shelter victim served; scalability. Goal attainment scaling or similar methods to elicit victim specific preferences.	Loss of community dwelling status for those who remain after mistreatment risk ends; both permanent and temporary nursing home placement is traumatic for older adults. Loss of non-abusing community supports. Fear of permanent institutionalization. “Transfer Trauma”. PTSD. Physical, verbal, and sexual abuse from resident to resident elder mistreatment (prevalence 20% per month) resulting in retraumatization. Similarly, abuse by nursing home staff. Nosocomial infection with pathogens such as COVID.
Families of Victims	Solace in knowing that loved one is safe and cared for. Reduced family distress. For family abusers, referral to appropriate resources (e.g. mental health services or substance abuse).	Distinguishing intentionally abusive caregivers from unintentionally abusive ones when victims’ desire visits/contact. How are these supervised? Who determines who can visit?
Other Nursing Home Residents and families	A source of potential support to co-habitating victims by other residents and their families which may be another emotionally meaningful activity	Exposure of vulnerable nursing home residents and nonshelter families to domestic violence dyads and potentially menacing abusers changing the culture of the nursing home environment. Ease of visits for all nursing home resident families when restraining orders are used for shelter victims.
Staff	Increasing job satisfaction / personal fulfillment in caring for this vulnerable population.	Potential confrontation with perpetrators and exposure to violence, safety concerns; chronic psychological distress from seeing victims of elder abuse. PTSD.
Nursing Homes Attempting to Replicate the Shelter Model	Important Mission likely to be embraced by the community. Potential new source of philanthropy for shelter activities.	Reputational risk from explosion in nursing home ligation wherein plaintiffs allege abuse in an elder abuse shelter; facilities adopting the shelter model may become litigation targets endangering solvency in some cases. Inability to replicate the model in facilities without philanthropy.
Referring Providers	Avoidance of “social admissions”; a potential source of improper placement for victims who are not sick enough to be admitted, but not safe enough to return to the community. Resource for community-based providers who believe that a victim needs immediate protection	Increased identification leads to an explosion of cases that cannot be accommodated by shelters, resulting in the expensive use of medical beds for social admissions such that surrounding hospitals become the actual shelters but without the resources or expertise of nursing home shelters. If victims requiring protection aren’t eligible for shelter services or can’t be accepted during off hours / within the necessary timeframe, another option must be identified.
Communities	Educational programs offered by shelters to increase community awareness	Duplicative in communities that already have such programs that predate shelters, such that funds and efforts are not cost effective. Increase in identification leads to large volume of cases that cannot be handled by shelters or their communities putting “outed” victims in danger without resources.
Payors	Cost savings to Medicare and Medicaid as prevention may result in better downstream victims’ health. Shelter acceptance/access rater by insurance and citizenship status.	Premature nursing home placement leading to increased costs to Medicare and Medicaid even after abuse risk has been mitigated. Inflation of “shelter days” after risk is mitigated because Medicare and or Medicaid is now paying for induced skilled or unskilled services that are misattributed to shelter activities.