Elder abuse and neglect are serious yet preventable problems in the United States. Approximately five million Americans are estimated to be victims of elder abuse and neglect each year, and just one in 24 cases are reported to authorities.[1] Victims often suffer from both elder abuse and neglect, so as I refer to elder abuse or neglect throughout this article, understand that it could very well mean both.
The Harris County (Texas) Elder Fatality Review Team (EFFORT[2]) was formed in 2003 with a grant from the American Bar Association. EFFORT aims to identify and provide recommendations to prevent premature elderly deaths caused by elder abuse or neglect in our county. The team also examines and makes recommendations on preventable deaths of individuals with disabilities of all ages who could be victims of abuse and/or neglect.
The concept of an elder abuse review team dates back to 1995, when the Baylor College of Medicine Geriatrics Program at the Harris County Hospital District and the Texas Department of Family and Protective Services Adult Protective Services Region VI noticed an increase in the reports of elder abuse or neglect in the county. After meetings between both groups, the Texas Elder Abuse and Mistreatment Institute (TEAM) was officially established in 1997, followed by EFFORT several years later as a separate program.[3]
When I was hired as a forensic nurse death investigator in Harris County in 2003, I served as one of the founding members of EFFORT. In 2021, I transitioned into the co-director position, a post I still hold. Although I’m currently in academia, I worked full time for years, and now as a consultant, for the Harris County Institute of Forensic Sciences as a board-certified forensic nurse and an American Board of Medicolegal Death Investigators qualified medicolegal death investigator.
Identifying Cases of Possible Abuse or Neglect
The EFFORT team meets monthly and includes leaders from hospitals, clinics, emergency medical services, district attorney’s offices, adult protective services, the Texas Medicaid Fraud Control Unit, the Ombudsman Program [4], law enforcement, and the medical examiner’s office. It’s essential to have representatives who are change agents within that organization so that any system-level changes that are discussed can be taken back to the organization with a strong chance of being affected. Elder deaths are often expected and, as a result, frequently undergo inadequate medicolegal death investigation. That’s an issue that the EFFORT group regularly encounters when reviewing cases for possible abuse or neglect. The engagement of a representative from the medicolegal death investigation system, the district attorney’s office, or both, are necessary for providing information about the cases at EFFORT meetings to maximize the group’s discussion—either as members of the team or consultants.
At each meeting, a case is presented, and we go around the room and identify any historical touchpoints that the various agencies may have had with the person involved. I typically provide an in-depth summary of the encounter, offering more context of the events leading up to the death and potential opportunities for a different level of intervention, service, or regulation to be put in place. The members then anonymously vote if they believe the death could have been prevented. To date, the vote is to capture the opinion of those present. No adjudication occurs. We just discuss avenues for improvement.
One of my major roles for EFFORT is to identify cases. To identify cases, I ask the data quality personnel at the Institute of Forensic Sciences for a monthly report of deaths on people over 65 who had an autopsy. I also receive direct communications from forensic pathologists or medicolegal death investigators regarding cases involving people with disabilities. Cases come from various settings, including residential deaths where an individual had been living with family, caregivers, or in boarding homes, nursing homes, hospitals, assisted living facilities, or hospices.
I then review or screen the medicolegal death investigator report for cases in which the decedent had been dependent upon another person for any activity of daily living and there are indications of abuse or neglect (EFFORT does not include motor vehicle crashes, most overdose deaths, or suicides). These cases, approximately 200-300 per month, are screened with a focus on deaths for which there are concerns over medical neglect, financial exploitation, and those who may have had physical or sexual abuse. Other elder abuse fatality review teams may use different criteria; there are no specific standardized rules for fatality review teams.
To identify an opportunity for system-level improvement, each case undergoes a deep dive review by the EFFORT members looking at the circumstances of death. With each review, we examine touchpoints or historical visits or interactions in the various systems that had contact with the decedent. One opportunity of improvement we’ve seen is to reinforce screening of elder abuse or neglect among emergency medical technicians to include both calling and documenting the calling of Adult Protective Services (APS). In theory, APS would respond and take actionable steps.
Asking Different Questions
Because we typically only review cases in which there was an autopsy at the Institute of Forensic Sciences, we’re missing a lot of possible cases. The deaths of many elderly individuals and those with a disability may not have been reported to the medical examiner’s office because those deaths are classified as natural and no autopsy is performed. When a deceased elderly person is brought into the Institute of Forensic Sciences for a forensic examination, the initial medicolegal death investigation may also lead to an assumption that the manner of death was natural and forensic pathology staff may only perform an external exam, not a complete autopsy. On a few occasions, I did bring external examination cases to the EFFORT meeting. While the interdisciplinary team did have concerns surrounding the death, the limited information we had kept us from voting on whether the death could have been prevented. Typically, if the forensic pathologist is not going to do an autopsy, they’re less likely to gather medicolegal information beyond the initial information of the death.
If we expanded the EFFORT criteria to always look at both external exams and autopsies, and we are able to receive sufficient evidence about each case, our case volume would clearly increase, and we already are a year and a half behind on reviewing cases. But this backlog presents an opportunity for improvement – providing additional information to the medicolegal death investigation community to recognize that elder abuse or neglect requires a different approach to the initial medicolegal death investigation. For example, suspicious circumstances in this population often extend beyond obvious physical injury. Thus, a screening tool is needed to first identify a person dying with concerns of abuse or neglect and are dependent upon another person or persons. Then, if screening positive, identify additional information for investigating medical neglect, financial exploitation, or other forms of abuse or neglect is necessary. That’s what we see in the EFFORT cases, and we have an opportunity to improve all investigations of elder abuse or neglect by developing strategies to offer medicolegal death investigators a feasible investigation path to address these circumstances. I’m hopeful that we can provide a best-practice recommendation for medicolegal death investigators for elder abuse or neglect deaths in the future.
In short, the question we need to ask is: Did the decedent depend on anybody for ambulating, bathing, toileting, eating, medication administration, or other services essential to their daily life? If the answer is yes, and there’s an indication of abuse or neglect based on set criteria, that should automatically trigger additional medicolegal death investigation questions. Those set criteria include:
- Suspicion of financial exploitation.
- Social or emotional isolation or abuse.
- Delayed or absent care for injury or acute illness.
- No access to needed mobility devices.
- Known expressed concerns of abuse and/or neglect (concerns expressed by any other individual during the decedent's life, terminal hospitalization, or the death investigation).
- An environmental living condition that is a threat to health or safety.
- Chronic disease with no documented primary medical care within one year.
- Poor hygiene or inadequate nutrition.
- Unexplained physical trauma.
- Untreated, significant decubitus ulcers.
A person can be dependent upon somebody as a resident at a nursing home or being taken care of at home and have absolutely no concerns of abuse or neglect. It happens every day and is the scenario representing how the vast majority of persons, as they age, would die – a ‘natural’ death. However, if they are dependent on someone for their essential needs and that’s not occurring, that is a reason for suspecting medical neglect or financial exploitation and should be further investigated by the medicolegal authorities.
EFFORT Leads to Change
Law enforcement involvement in EFFORT led to the Houston Police Department recommending that the city enact an ordinance, passed in 2018, that requires any location that calls itself a boarding home, with three or more residents, must be licensed. This ordinance is important because unlicensed boarding homes are ripe places for exploitation — if you’re taking somebody’s social security, Medicare, or Medicaid check, and you’re spending it for something other than for the person who needs it, that’s a crime.
Houston is only a part of Harris County, so we were seeing the distribution of these types of deaths or scenarios in areas outside of the city limits because Houston had these laws, but the county did not. Recently though, Houston and Harris County law enforcement have been working more closely together. Now they both have boarding home and group home divisions to ensure these homes are licensed and comply with the laws. I would say that that’s a huge accomplishment.
Partnerships Are Essential
When starting an elder fatality review team, partnerships are essential. It’s necessary to involve your partners and leaders from within the justice system and the larger community. Required members include leaders from the district attorney’s office, a medicolegal death investigation agency, and law enforcement. You also need community partners who work in the space of older adults, such as representation from the public health department, hospitals, clinic providers, and adult protective services.
Start your effort by bringing together people who have a vested interest in improving the health and safety of older persons in the community. Recognize that you’re going to face barriers. Communication is key. We constantly communicate with members, keeping them appraised of what’s going on locally, at the state level, and nationally.
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