Sacramento County Adult Protective Services (APS) and Kaiser Hospital Case Management Response Team Jean Friedman, LCSW, Kaiser Medical Center-Roseville, Manager Medical Social Work Services Martha Haas, LCSW, APS Program Planner

History of Response Team Collaboration High profile senior deaths resulted in the Board of Supervisors, Grand Jury and Adult and Aging Commission recommending a community system of protection be established. Multidisciplinary workgroups recommended implementation of an APS case management unit for improved protection and service provision to senior and dependent adults.

Response Team Development and Implementation A group of representatives from Sacramento County Senior and Adult Services and local hospitals including Kaiser, Sutter, UC Davis and Catholic Healthcare West began meeting to design the program. In October 2006, Kaiser was the first hospital to contract with Sacramento County APS to provide case management services. Collaboration on this program gave both APS and Kaiser a way to provide case management services for their vulnerable population. Without the collaboration, APS would not be able to offer the service to the clients. All the hospitals were meeting at first and then some decided to wait and see how successful the first contracts were.

Case Management Response Team Goals Improve safety of seniors in their homes through care coordination and linkage to community resources Reduce inappropriate use of emergency department (ED) Reduce repeat ED and inpatient hospital stays due to self-neglect and inappropriate care Improve APS response time to hospital resulting in improved client safety and outcomes Bottom line is the client safety and well-being. Even though reducing recidivism and hospital costs was a driving force, Kaiser really wanted case management to be the eyes and ears to ensure the client is safe in their home.

Target Population Sacramento County residents, 65 years of age or older, receiving medical care at Kaiser, and have one or more of the following: Client has been abused or neglected Client has repeated ED and hospital admissions Client abandoned with no family or legal representative Client has little/no support and complex psycho-social issues Client in recovery from alcohol or drug abuse Client medically non-compliant due to cognitive impairment Client exhibits behaviors placing client’s safety at risk with no appropriate plan to ensure their care and safety Most referrals involve self-neglect – probably more than 75%.

Program Parameters APS assigns one social worker to work exclusively with program clients. Kaiser dedicates a liaison to make referrals and staff cases. APS social worker responds to referrals within 24 hours - 3 days, depending on the urgency of the situation. APS social worker carries up to 25 cases at a time. Program services are provided at least 6 months and occasionally more than a year. Dedicated worker ensures quicker response time from APS. APS social worker calls liaison back immediately to consult on case and determine response time. Provide services at least 6 months – reality more like 6 months to a year. Conservatorship cases take longer.

APS Case Management Response Team Members Case manager (APS social worker) Family service worker Public health nurse The family service workers and the public health nurses are valuable, necessary components to the program. They are often able to form relationships with the client when the social worker cannot. The PHN can often get the MD on the phone much easier than the social worker. PHN can get more information from health providers!

Referral Process Hospital liaison calls in referrals to the APS intake hotline. APS assigns two intake hotline social workers to accept referrals from the hospital liaisons. APS intake contacts the designated APS case manager with the referral information. The APS supervisor is notified also but the info is given to the social worker right away due to the time constraints associated with the program.

APS Response Team Service Provision Assesses clients via face-to-face meetings Develops interventions and service plans Facilitates coordination of communication among medical providers and the client Educates clients and caregivers about illnesses/care needs to improve health/safety Team purpose – to enhance and expedite access to and linkage with community resources to address the health, mental health and social service needs. FSW – Transport Model for caregivers Interim chore worker Home visits PHN Consult with health professionals abt. Client environment Education re: diagnosis Encourage client compliance.

APS Response Team Service Provision (cont.) Assist the client/family members in making difficult decisions and utilizing resources. Assist with planning for placement. Submit conservatorship applications. Facilitates linkage to community resources Participate in monthly case management staffings.

Program Data Quarterly reports highlight number of visits with client, types of interventions with client and linkage to community resources Monthly case management meetings Difficult to obtain data on reduced number of ER visits and inpatient hospitalizations Out of 24 cases currently open to Kim, only 4 have had return ED visits or in-patient hospitalizations. One woman has been open for 17 months awaiting conservatorship. She has had 4 ER visits for falling. One couple have each had 2 ER visits which have been legit. They are both waiting on conservatorship and need to be placed. They have been open 17 months also. One woman has been open 5 months and was recently sent to the ER by the APS nurse in consultation with the physician. APS response time was great except for one client who was in jail and another who was avoiding APS because they do not want services.

Program Funding Sources Contract utilized as county match State funds Federal funds County share for program -15% State funds – 35% Federal funds 50%

Lessons Learned Hospitals need a data analyst to collect outcome data on ED visits/hospitalization Loosen program eligibility criteria to allow some referrals related to current ETOH and some mental health issues Frequently remind hospital staff of program Survey involved APS and hospital staff regarding areas for program improvement Very time intensive/costly to obtain outcomes related to ER and in patient recidivism. Would need to review each client’s medical record to determine whether any ER visits or hospitalizations were appropriate/necessary. Allow clients with substance abuse problems, even if they are not currently in recovery. The team may be the ones who get the client into recovery!