Working with Self-Neglecting Vulnerable Adults - What San Francisco APS is Trying

Akiles Ceron, MSW

Gloria Wong, LCSW Ragina Gibson, LMFT

San Francisco APS

High Risk Self-Neglect Unit (HRSN) Pilot Program

2018 ICHC Theme: “Think Outside the Boxes: Innovation in Action”

A new approach in APS Practice, focused on:

1. Safe and independent living

2. Eviction Prevention

A State mandated program Receive and respond to reports of abuse Abuse includes neglect and self-neglect Provide preventive and remedial services Elders (65 and over) and Dependent Adults

What is APS?

What is Self-Neglect?

• Failure of an elder or dependent adult to satisfy these needs below for himself or herself as a result of poor cognitive functioning, mental limitation, substance abuse, or chronic poor health:

1. Personal hygiene, or in the provision of food, clothing, or shelter.

2. Medical care for physical and mental health needs.

3. Protection from health and safety hazards.

4. Prevention from malnutrition or dehydration.

SF APS Dashboard

What is it that SF APS Workers see?

Health and Safety Hazards:

Hoarding – Persistent difficulty discarding personal possessions, even those with apparently useless value.

Squalor – Unsanitary conditions resulting from problems with personal/domestic hygiene. Examples include rotten food and evidence of human/animal excrement.

What does this mean for the Adult at Risk?

Potential loss of housing: Deterioration of their environment often results in code violations, and leads to evictions. Potential for injury:

Hospitalization

Loss of independence

The Self-Neglect Equation

An uphill battle for client and worker…

We had to do something . . . We partnered with our Controller’s Office to gather data.

SF Controller

Job shadows and a social

worker focus group

A national peer survey

An analysis of case data from

more than 22,000 APS cases

from 2012-2015.

The analysis highlights the key

drivers of case complexity and

informs business decisions

around unit organization and

caseload management.

Link to report:

www.tinyurl.com/SFControllerAPS

What stood out?

Cases involving substance abuse = Short Duration

Cases involving a housing issue = Longer Duration

-Average of 4 Months to Resolve Health and Safety Violations

-Average of 4.4 Months to Remove the Threat of Eviction

° Investigation ° Crisis Management ° Resource Referral

Traditional APS Work

Thinking Outside the Box

Coordination:

o Code Enforcement Task Force

o Department of Building Inspection (DBI)

o Fire Department and Law Enforcement

o Environmental Health

o Behavioral Health

A New Approach:

Specialization

Standardized Tools

Longer Term Casework

Multidisciplinary Approach

High Risk Self-Neglect Unit

1. Prevent Evictions 2. Reduce Health and Safety Hazards 3. Reach Clients that are Reluctant and at Risk of Harm 4. Improve Collaborations Across Programs 5. Learn More about Hoarding and Cluttering 6. Collect Data on Outcomes to Review and Revise our Work

● Six licensed (LCSW and LMFT) APS Workers. ● A licensed (LCSW) APS Supervisor overseeing the unit. ● Lower Caseload than rest of the unit (6-8 new cases per month). ● Focused training on self-neglect issues for this unit’s APS Workers.

Unit Structure

Gloria Wong, LCSW

Problem Solving = A natural part of APS casework

High Risk Self-Neglect Unit - Intake Criteria

1. An existing client of San Francisco Adult Protective Services 2. The client is housed, AND 3. The client is either: a) At risk of eviction or losing own home due to severe

environmental hazards or other severe self-neglecting behavior, OR

b) Multiple ER visits or hospitalizations within the last six months.

Making It Work!

Longer term intensive case management approach vs. brief crisis intervention

Using Motivational Interview and Harm Reduction for engagement

At least bi-weekly home visit with the client during the

first month to establish rapport

Collaboration of effort with community partners

Assessment Tools

Bio-psychosocial assessment

Mini-Cog (cognitive impairment screening) PHQ-9 (depression screening)

Clutter Image Rating Scale

Outcome Measurement

Outcomes Matrix published by California Welfare Directors Association

Five outcome levels: In-CrisisVulnerableStableSafeThriving Comparison of data collected at initial assessment and

case closure, for example PHQ-9 scores Recidivism Rate

Who have we served?

From May 9, 2017 to March 9, 2018, the HRSN Unit has handled 285 cases.

Unit currently has 109 open cases Of the 285, 49% of the cases had either unpaid bills

(utilities, rent, mortgage) or risk of eviction.

Outcomes!

74% of clients reported as stable or better at closure

PHQ-9 Depression Screening

Respondents* PHQ-9 Score Change

52 Depression Score Decreased

43 Depression Score the Same

9 Depression Score Increased

* of 285 clients, 104 completed pre & post screening

104 clients responded to pre-and post screening • 67 had mild-severe depression at first screening • At closure, 23 had mild-severe depression

Recidivism for HRSN Unit vs other APS Unit

*Over the 10-month period since unit was taking cases

*4370 = HRSN

Unit

Returning

Clients

Reports

Received by

Unit

Adjusted Pct

Recidivism

Unit 4370 26 285 9%

Program Avg 930 5711 15%

Ragina Gibson, LMFT APS Worker

Client Demographics

65 yr old

Black Male

Clt is currently single and lives alone

Clt lives in a 55+ condo in San Francisco

Born in Chicago

Clt's parents are both deceased

Clt has 2 siblings who clt states he is not in communication with

Clt ihas been married and divorced

Clt and ex-wife have 4 children, only 3 of his children are still living, and clt reports he is not in communication with his children

Clt was in the US Airforce

Clt is a Vietnam Vet

Clt's reports he attended De Anza College and San Jose State

Clt was last employed with HUD

Clt retired in 2014

Medical history

client has a history of strokes (2)

client has been diagnosed by the VA with the following:

Sick Cell traits

Microcytic Anima - Narrow Angle

Vitamin D deficiency

Impaired Glucose Tolerance

Importance (organic origin)

Cerebral Infection Begin essential hypertension

Keloidscar

Colonic Polyps

Mixed hyperlipidemia

Date current report was opened: 6/26/2017

RP called to file another report regarding client self-neglecting.

Client is at risk of losing his condo due to client not paying his mortgage.

Client’s unit is scheduled to go for public auction on 7/25/17.

Client does not have a phone and he does not answer the door.

RP has connected client to a credit counseling service agency that helps

clients address their financial problems, but client will not follow up.

RP has not seen client since April, and RP made an attempted HV on

6/23/17.

Client is not following up with his primary care physician.

Current APS Report

ENTRY WAY

CLIENT’S BATHROOM

CLIENT’S BEDROOM

CLIENT’S KITCHEN/LIVING ROOM

Developing a Connection

High Risk Self-Neglect Clinical Intervention

Goal: Reduce client’s risk for future incidence of financial and medical self-neglect through the use of clinical interventions: Developing trust through active listening and building

rapport. Motivational Interviewing. Cognitive Behavioral techniques / Harm Reduction. Use frequent reality testing. Prepare the client for transition to the next stage of

change.

Collaborations with Community Partners

VA SW

VA IMPAC Team

VA psychiatrist

VA PCP

Mortgage loan services company

Mayor’s Office on Homelessness

Bankruptcy Lawyer

Bankruptcy Court

Credit counselor

Fiduciary/Case Management

Real estate agency

Tax Franchise

Cell phone company

USPS

Bank

Owner of property client has rented room from

Heavy cleaners

Property management of client’s condo

HRSN Service Plan

1. Investigate and evaluate allegations of neglect of client's own self-care and client's finances.

2. Obtain fiduciary to analyze and manage client's financial situation. 3. Refer to credit counseling. 4. Refer to bankruptcy lawyer to stop Trustee Sale of client‘s condo 5. Refer to real estate agent. 6. Assist client in filling out bankruptcy paperwork and obtain documentation required

and submit to Bankruptcy lawyer. 7. Help client to obtain all tax returns required (2014-2017). 8. Complete and file tax returns (that client did not file) for the years of 2015 and 2016. 9. Create TFS Bill Pay account for Chapter 13 bankruptcy payments. 10. Accompany client to bankruptcy court. 11. Refer client to Home Delivered Meals. 12. Help client to find a room to rent. 13. Go over lease agreement with client, have client sign lease agreement and submit to

landlord. 14. Assist in obtain moving boxes and moving supplies. 15. Assist in obtain personal hygiene items, provide copy of lease agreement, write up and

post the rules of the house, and in a place where client will be able to see it.

Client’s Current Status

Client is living independently in the community renting a room.

He says that he is more comfortable and feels happier in this other neighborhood.

He is not living in clutter or squalor anymore.

We have arranged for at-home support, e.g. laundry, the up-keep of his room, home delivered meals, errands, etc.

Has a private fiduciary and a private case manager.

Home is pending sale at market value or above.

QUESTIONS?