Replication and Evaluation of the RISE-APS Model In New Contexts

Elder abuse and self-neglect (EASN) are recognized by researchers, clinicians, and policymakers as pervasive problems with serious consequences for the aging population. EA is defined as an intentional act or lack of action by a person in a relationship involving an expectation of trust causing harm or risk of harm to an older adult; it comprises abuse (emotional/psychological, physical, sexual), neglect, and financial exploitation. SN, closely associated with EA, refers to the failure or inability of a person to satisfy their basic needs and protect themselves from harm. About 10% to 29% of community-dwelling older adults in the U.S. experience EASN each year. EASN is associated with serious consequences, such as premature mortality, poor physical and mental health, increased healthcare costs and utilization, and nursing home placement.

Without effective prevention and intervention strategies, the absolute scope of EASN will expand with the growth in the older adult population. In turn, community based EASN response programs, such as Adult Protective Services (APS), are under increasing pressure to address rising numbers of EASN case referrals and victims' need for support. Despite an increasing volume of case referrals, our understanding of effective EASN interventions represents a major gap in the field. Systematic reviews routinely find that the quality of EASN intervention research is weak and, in turn, strength of evidence is limited.

APS is the primary public agency responsible for receiving and responding to reports of EASN in the U.S. The current APS practice model typically focuses on three main phases: case intake, investigation/ assessment, and substantiation/determination. In 2021, at intake, APS received about 1.35 million reports of maltreatment allegations, and it accepted almost 797,000 cases for investigation. Among investigated cases, nearly 269,000 cases were substantiated. Although some APS programs provide services/referrals to address immediate client safety needs during and/or following the investigation phase, generally APS systems lack a dedicated, defined, and evidenced-based intervention phase to address underlying needs and risk factors. ACL guidelines recommend that effective APS models include a distinct service planning and intervention phase.

RISE (Repair Harm, Inspire Change, Support Connection, Empower Choice) was developed to address this intervention service gap in the APS EASN response system, based on prior research, theory, consultations with older adults and key stakeholders, and pilot testing. It was designed to address challenges that historically have limited EASN intervention capacity to address underlying case needs and risks, strengthen social supports, fulfill client priorities, and achieve more sustainable, holistic outcomes. RISE is informed by an ecological-systems intervention perspective, suggesting that effective models of EA intervention should have the capacity to work with both older adult victims and alleged harmers, their relationships, as well as to strengthen social supports surrounding them to address the full scope of risk factors that characterize a case. RISE is also informed by a person-centered practice orientation grounded in principles of client self-determination, cultural humility, and relationship building. RISE operates at Relational, Individual, Social, and Environmental levels of ecological influence and its core modalities seek to Repair Harm (restorative approaches), Inspire Change (motivational interviewing), Support Connection (teaming), and Empower Choice (supported decision-making).

Under the RISE-APS model, APS workers refer clients to RISE (with their consent). RISE "advocates" implement the intervention, engaging and building relationships with the victim, (and if they want, the harmer or others, or on their relationships) and working collaboratively with one or more of them. Advocates receive training in and employ specific core modalities that define the RISE model. Motivational interviewing, which has shown evidence to reduce EA re-victimization risk and advance intervention goals, is used to help victims and harmers resolve ambivalence and elicit openness to the change process . Teaming is employed to engage both informal and formal supports to surround the victim (and others if wanted), leveraging the known protective mechanisms of social support in EA cases (MacNeil et al., 2022). Restorative approaches are used with victims, alleged harmers, and others to help repair harm, hold harmers accountable and, where appropriate, restore relationships. Given the importance of the client-practitioner relationship in facilitating successful case outcomes, advocates are trained in engagement skills to navigate this threshold phase. RISE model core modalities described above were selected in part because they foster client-practitioner engagement and stronger relationships. To help facilitate behavioral change, goal setting is used as a dynamic process throughout the RISE intervention using a collaborative strategy called Goal Attainment Scaling, which has shown feasibility with APS clients.

RISE advocates deliver the intervention in person, over the phone, or using virtual teleconferencing methods, depending on client preference and safety needs. Interactions involve talk-based forms of support. Cases remain open, on average, approximately 5 months across phases of engagement, action, monitoring, and closure and involve sessions approximately 1-2 times/week. Similar to other EASN response programs, it is not possible to provide standardized information regarding the number and frequency of sessions or interactions with each case. EASN cases are highly heterogenous with varying needs, and outcomes of success across cases are multifarious. Cases are different in regard to mistreatment type(s) (or presenting issue), urgency and problem severity, circumstances and needs, perpetrator relationship and dynamics, and a host of other factors. Given the highly contextualized nature of EA cases, the number and frequency of RISE sessions vary across cases.

Beginning as a pilot in two randomly selected Maine counties in 2019 in partnership with APS, the RISE-APS model has since been scaled throughout the entire state. The RISE-APS ((R)epair Harm, (I)nspire Change, (S)upport Connection, €mpower Choice - Adult Protective Services) model has demonstrated evidence of feasibility, acceptability, and improvement in case outcomes (efficacy) in Maine, where RISE and APS have established a successful, complimentary partnership and referral process involving over 1500 cases to date. Among active clients, 77% have reported that RISE met most or almost all of their needs, and 89% reported being mostly or very satisfied with program services. In qualitative interviews, Maine APS caseworkers who refer cases to and work directly with RISE describe the partnership as collaborative and as integrating complimentary services; they also commonly report that RISE contributes to their own psycho-emotional well-being. Cases receiving the RISE-APS model in Maine significantly showed a 55% lower likelihood of re-investigation (recidivism) back in the APS system compared to cases receiving APS service alone. This protective effect of the RISE-APS model applied to nearly all forms and combinations of EASN. These findings suggested that both RISE and APS play critical, complementary roles in Maine within the overall EASN prevention/response system and that the combination of RISE-APS services appears to be most effective.

Goals and Objectives

Research shows initial evidence for the RISE-APS model in Maine. Further work is required to understand whether the RISE-APS model works in other contexts. Research is required to test the adaptation, implementation, and effectiveness of the RISE-APS model in different locations that serve older adults and families from varying communities. Addressing this need, this study will test the adaptation and effectiveness of the RISE-APS model in three new locations that each involve an APS program (making referrals to RISE) and a non-profit organization (housing and administering RISE): Ventura County, California (Ventura County APS, ONEgeneration); Harris County, Texas (Harris County APS, Harris County Area Agency on Aging), West Central, Texas (Northwest District APS, West Central AAA), and Cuyahoga County, Ohio (Cuyahoga County APS, Benjamin Rose). This study contains the following objectives and phases:

1. Adapt and implement the RISE-APS model in three new contexts
2. Evaluate the RISE-APS model implementation and effectiveness in three new locations