Dementia Scenarios

The probability of Tribal participation is greater when one can show Tribal gatekeepers that they have taken the time to learn the value of culture, tradition, and humility. Tribal values emphasize family/clan/group/Tribe, not the self or individual as in Western society. When working with Tribal entities it is important to represent the greater good of the group. Questions are best framed in a manner that conveys awareness that our individual and group behaviors can help and/or hurt current efforts to solve community problems.

Encouraging Trust Among Tribal People

1. Show respect for Elders, and tribal and spiritual leaders, by acknowledging and appreciating their roles and expertise. Seek their advice as the experts of the community.
2. Schedule meetings and events around meals. Foster the sense of importance of eating together combined with community sharing.
3. Always publicly acknowledge tribal participation at meetings. Make sure non-tribal participants know who is in attendance from the local reservations, and those recognized as leaders. This is a good time to recognize individuals new to the community, and to praise an individual’s or organization’s recent success.
4. Model a spirit of cross-cultural collaboration by including and recognizing the efforts of both tribal and non-tribal entities throughout your event.

Engaging Tribal Leadership

1. Know your local tribe(s) and where the reservations are located. If you are in an urban area, know which tribe(s) are acknowledged to have occupied the land where you or your training is located.
2. Attend a local community event (gatherings, pow wows, storytelling, and other cultural events). Identify the leadership at the event, and humbly and respectfully introduce yourself.
3. When giving your introduction, give personal and family background in addition to professional. Who you are and where you come from is important in Indigenous communities.
4. When asking for support, frame your request in the context of how it will help the Tribal Community.
5. Be yourself. Be sincere, transparent, and follow through with each commitment you make. You run the risk of being viewed as another in the chain of broken promises and dishonor if you fail to follow through.

Hosting an Event

1. Ask representatives from the local tribes to help officially welcome attendees.
2. When Elders and tribal leaders are attending, make sure to recognize them formally in front of the group.
3. When a new tribal representative arrives make sure to personally take the time introduce them to everyone before the meeting starts. This allows them to begin building face-to-face interaction.
4. Model cross-cultural collaboration by your own behavior. Create the time and space for everyone’s participation and point of view.
5. Do not to imply that you are an “expert” about a tribe, nor correct any tribal person when they are speaking about tribal or cultural affairs. Remember that much of the published literature about tribal people was written by non-Native Americans.
6. Do not try to impress or flatter tribal people by dressing as a tribal member.
7. At times, it is best to be silent. Practice good listening. Don’t interrupt a speaker.

Recognize that time may not have the same meaning for tribal members. Meetings may not start on time or end on time. There is more value in the process than the structure of the meeting. Build in “conversation time” prior to and after the meeting, to allow time to address issues and build connections.

Respect is by far the most important aspect of successful collaboration with the Native American community. It is crucial to be aware of the great status that a chief or chairman of the tribe has. Remember that Native American women, people, and Tribes are the experts on their own lives. Walk into meetings with sincere attitudes and the goal “to listen, understand, and learn to help.”

Resources

• Lidot, T., & Kolb-Williamson, K., Tribal STAR Program (undated resource). Tribal Star: Tips for following protocol when working in Tribal communities.
• Tribal STAR Program. (undated resource). Recommendations for developing and maintaining tribal relationships.

Develop and cultivate contacts with the local tribal community programs, Indian Health Center, social services, and Elder services programs. You may need to submit a written request about your project to the tribal secretary, and ask to be put on the tribal council agenda. The elected tribal leaders may not be your first contact with the tribe. Reach out to the Elders or other traditional leaders in the community. Maintain a practice of patience for tribal procedures. Many tribal communities practice proper introductions for each tribal member present. Take the time to sit and talk with the members of the tribe. Build long-term relationships, before you discuss business. When presenting, make the tribal Elders the center of your presentation, but be brief. Solicit support, input and guidance.

Remember that the Indigenous community is the expert and their support and guidance in creating long-lasting relationships will be an important factor in your ability to serve tribal communities.

What if I Am Not Native?

Learn as much as you can about the local tribe(s), especially their history and relationship with federal and state programs. Take the time to learn about key tribal organizations. Express commitment to being part of the community. Attend community functions (e.g., pow wows, cultural gatherings, health fairs).

Engagement Strategies

Respect the Tradition of Oral History and Personal Interaction

1. Face-to-face interaction is important. While modern technology facilitates communication in a variety of ways, it is culturally congruent to have face-to-face interaction, particularly on difficult matters.
2. Initial meetings held on tribal land demonstrates a willingness to engage at sites that are significant to the tribe.
3. Consider engaging in a talking circle as opposed to following a traditional meeting format, and negotiate communication strategies that are comfortable for both parties. Consider engaging in tribal traditions that open and close each meeting, such as a prayer, sharing of food, and smudging.
   1. A Talking Circle is a Native American traditional way for people to solve problems. Every participant sits in a circle, a token (e.g., a feather, or a talking stick) is passed clockwise around the circle. Each person is able to speak for as long as they wish about their concerns or topics they wish to address. Then when finished the token is passed to the next person. The token may be passed around the talking circle many time as needed.
   2. Prayer is referred to traditional worship practices of Native Americans. Sacred narratives and beliefs are deeply based in Nature and connection to the earth.
   3. Smudging Ceremony is a Native American practice used to cleanse and purify the body, mind, and spirit. Smudging is used to remove negative energy, attract positive energy, and restore balance using plants such as tobacco, sweet grass, cedar, and sage.

Recognize Historical Trauma

1. There is a history of deep distrust of government, particularly of the government’s effort to “help” Native Americans. Many Elders harbor painful memories, unresolved issues and anger. Establishing long–term relationships will help re-establish trust.
2. First attempts at collaboration may be met with resistance. Advance efforts by asking tribal members what they need in order to move forward.
3. Use empowerment strategies. Ask tribal members how they envision successful collaboration. Remain consistent in following through on your promised actions.
4. Attend topic trainings on local tribe history, engaging Native American communities, and other tribal practices.

Understand how Native Values Conflict with Current Policies/Practices

1. Western professional practice is rooted in formal relationships with clients. Many Native American tribes value a more informal connection. This connection may conflict with current professional boundaries.
2. Consider working with agency administrators on more culturally appropriate interventions with Native Americans. Designating a conference room where smudging before meetings can be conducted, to help create a more positive space for important discussions.
3. Review, and revise as able, any policies and procedures that may interfere with more culturally appropriate interventions.

Partner with Tribes and Agencies

1. Look at the needs of the tribe(s). Are there ways to partner on projects to achieve a goal?
2. Consider partnering on grant funded projects. Can the government agency provide a grant writer and the financial knowledge when collaborating on grant applications?
3. Consider if tribes are aware of federal, state, or local funds they can access.

Culturally Responsive Communities, Tribes, and Native Organizations increase Cross-Cultural Understanding through the following Actions

• Provide encouragement for community members who show an interest in pursuing a career in social work, health and human services, and education.
• Provide opportunities for mentoring, job shadowing, and internships.
• Establish a welcoming and supportive environment for new personnel moving to the community/organization, and provide opportunities for these professionals to participate in cultural events that strengthen relationships and support cross-cultural collaboration.
• Sponsor regular meetings with community members, leaders, organizational staff, and supervisors to develop ways to incorporate cultural values in their programs.
• Implement a support structure for Elders and assist organizational personnel to involve the Elders in program development. Elders will help foster the incorporation of traditional knowledge, values, and beliefs.
• Coordinate services of all local and regional social services, health, economic, cultural, and educational programs for mutual support and benefit in the communities.
• Host an annual community workshop (with food) including tribal staff and clients to discuss ways organizations can increase positive outcomes within the community.
• Encourage all members of the elderly services circle to take an active role in guiding new comers to understand the local cultural practices and aspirations to become contributors to community life.

For more information, visit the Tribal STAR website.

Resources

• Tribal STAR Program. (undated resource). Recommendations for developing and maintaining tribal relationships.
• Mi’kmaw Spirit. (March 25, 2016). Mi’kmaw Spirituality: Talking circles.
• Spirituality and Health. (October 19, 2012). The ancient art of smudging.
• Assembly of Alaska Native Educators, Anchorage, AK (February 3, 2003). Guidelines for Cross-Cultural Orientation Programs.

When interviewed, Native American elderly persons typically do not report experiencing abuse or neglect when asked directly. However, when using the alternative terms “disrespect” or “bothered” many elderly persons discussed incidents that included abusive acts.

It is important to be aware of language, cultural sensitivities and aspects of practice that differ from other ethnicities while working with Native American elderly. It is also important to consider the role of the community and family in Native culture. As an example, Native American elderly feel it is their role to take care of the entire family. Some people may perceive this as a form of exploitation. It is important to consider the elderly person’s willingness, and desire to provide or take care of their family, how this reflects their cultural traditions, and the contributions from other family members to the well-being of the entire family to ensure the Elder’s generosity is not being exploited.

The following are examples of interview questions you may use to assess an elderly person’s risk of neglect or physical abuse. When interviewing Native elderly, make sure to allow them time to tell their story. This method is often more effective than direct questions.

Recruiting Native elderly, who are fluent in the Indigenous language to serve as translators can be effective when interviewing Native elderly.

Background Information

1. What is your name?
2. Do you have any close relatives?
   1. Identify nature of relationship, names, addresses, phone numbers of any relatives.
3. Who are some of your close friends?
   1. Identify names, addresses, phone numbers, and length and nature of relationship.
4. Are you close to any of your neighbors?
   1. Identify names and addresses.
5. Does anyone visit you on a regular basis?
6. When is the last time you saw a doctor?
   1. Who is your doctor?
   2. Who took you to your last doctor’s appointment?
7. Have you been diagnosed with any medical conditions?
8. Are you taking any regular medications?
   1. Do you take medications as prescribed?

Housing Questions

1. Where do you live?
2. Do you own your home?
   1. How long?
   2. Whose name is on the title of the house?
3. How long have you lived in your current residence?
4. Does anyone live with you?
   1. Identify names and relationships.
   2. Do they pay rent?
   3. Do they provide any services for you in exchange for staying there?

Caregiver

1. Do you have a caregiver?
2. How long has your caregiver been involved with your care?
3. Does your caregiver get paid? If yes, how much?
4. Who pays your bills or manages your finances?
5. Who signs your checks?
6. Do you drive?
   1. If no, who takes you to appointments, shopping, etc.
   2. When did you stop driving?
7. Does anyone other than your caregiver provides any services for you? If so, please describe.

General Finance Questions

1. Who handles your finances?
2. Who writes the checks?
3. Who pays the bills?
4. Who does your taxes?
5. Do you have a will or trust?
   1. Does anyone have a valid Power of Attorney for you?
6. Do you have an attorney?
   1. Name and phone number, if available.

Suspect Related Questions

1. How long have you known (use name of suspect)?
   1. How did you meet (use name of suspect)?
2. Does (use name of suspect) provide any services for you? If so, describe.
   1. Who hired (use name of suspect)?
3. How is (use name of suspect) compensated for any services provided?
4. Did you ever give (use name of suspect) any loans or gifts (monetary or otherwise)?
5. Does (use name of suspect) owe you any money?
6. Do you owe (use name of suspect) any money?
7. Is there anyone else who can do the things (use name of suspect) currently does for you?

Case Specific Questions

Neglect

• Who is generally responsible for taking care of you?
• How long have they taken care of you?
• Who helps you with the following activities:
  • Shopping
  • Preparing meals
  • General Hygiene (showers, bathing, etc.)
  • Paying the bills including utilities
  • Cleaning the residence
• How long have you been in this position (circumstances of neglectful environment)?
  • If the person is immobile, go into details regarding their physical location.
• When was the last time that you saw a doctor?
• How long have you had these physical injuries?
  • Go through each injury.

Physical Abuse

• Are you being disrespected or bothered? If so, in what ways?
• Did you have any injuries before this incident?
• Were these injuries reported? If not, why?
• What happened to you during the current incident?
• Who did this to you?
• When did this happen?
• Did you see a doctor about your injury?
• What doctor did you see?
• Will you sign a medical release form so I can talk to your doctor? If yes, then have the Elder sign the form. If Elder has a valid Power of Attorney, then have that person sign the form instead.
  • A medical release form is a legal document that allows medical service providers to release confidential records after a patient signs an authorization form. Records must be kept confidential unless the patient submits a signed authorization to release the records to a named person or entity.

Resources

• Santa Clara County Law Enforcement. (2010). Elder and dependent adult abuse protocol.
• Baker-Demaray, T.B. (2009). Perceptions of Elder Abuse Among Native American Seniors (Master’s Thesis, University of North Dakota).
• U.S. Legal Forms. (1991-2023). Medical release form.

Highest priority is to ensure the safety of the elderly person while respecting their autonomy.

1. Does the elderly person accept or refuse intervention?
   1. Older adults in immediate danger should be separated from the suspected abuser whenever possible.
   2. If not in immediate danger then implement safety plans (e.g. safe-house placement, protection order from court, hospital admission).
   3. Educate the elderly patient about Elder mistreatment and the tendency for abuse to increase in frequency and severity over time.
   4. Provide assistance to alleviate causes of mistreatment (e.g. counseling, addiction rehabilitation, home health services).
   5. Refer elderly patient and family member to appropriate services, insure culturally appropriate services, if possible.
2. Does the elderly patient retain decision-making capacity?
   1. No: Discuss following options with Adult Protection Services
      1. Assistance with financial management
      2. Conservatorship
      3. Guardianship – The court may need to appoint a guardian to make decisions about living arrangements, finances, and care
      4. Court proceedings (protection orders)
   2. Yes: Discuss with the elderly patient
      1. Educate the patient about the incidents of Elder mistreatment and tendency for abuse to increase in frequency and severity over time
      2. Provide written information about emergency-assistance contact numbers and appropriate referrals
      3. Develop and review a safety plan
      4. Develop a follow-up plan for elderly patient
      5. Discuss effects of abuse/neglect on physical and mental health of the elderly person

Example: Elderly Health & Safety Screen

Statement 1
This primary care office would like to ask you some questions we ask all of our patients 60 years of age or older.

Statement 2
Many people are hurt by or have problems with their family members, loved ones, friends, or neighbors. Others may feel pressured by strangers or other care providers.

Statement 3
You do not need to complete this screen to see your doctor today, but your doctor is interested in your safety and may want to talk about any concerns you may have. This safety screen is private and will not shared with anyone without your agreement.

1. Has anyone close to you called you names or disrespected you recently?
2. Are you afraid of anyone in your life?
3. Are you able to use the telephone anytime you want?
4. Has anyone forced you to do things you did not want to do?
5. Has anyone taken things or money that belong to you without your permission?
6. Has anyone close to you tried to hurt you or harm you recently?

Statement 4
If you have answered yes to any of these questions or if you are feeling at all under pressure, we would like to have a representative from (designated local Victims Services agency) call you.

Resources

• Lachs, M. S., & Pillemer, K. (1995). Abuse and neglect of elderly persons. New England Journal of Medicine, 332(7), 437-443.
• University of Maine Center on Aging. (May 2, 2007). Elder abuse screening protocol for Physicians: lessons learned from the Maine partners for Elder protection pilot project.

Roles and Responsibilities

As sovereign nations, tribes are the direct recipients of federal funding from the United States Department of Housing and Urban Development (HUD). Each tribe chooses a Tribally Designated Housing Entity (TDHE), to administer its housing programs with these federal dollars. The TDHE may be a department within the tribe, a tribal housing authority with a separate board of commissioners, or a nonprofit organization. The entity designated by the tribe to receive HUD funds must comply with the rules and requirements of the federal program.

The tribal housing authority representative is designated as the main contact for all tribal housing authority services. As a member of the Elder protection team (EPT), this representative’s roles include, but are not limited to:

• Providing a designated representative from their agency to participate in regular EPT meetings.
• Providing information about the EPT to the tribal housing agency staff to increase awareness and referrals.
• Assist in the collaboration of additional agency services clients may need to utilize.
• Makes client referrals to the EPT for collaboration of additional community services essential to the wellbeing of an elderly person or vulnerable adult.
• Shares client information to the EPT, when appropriate
• Assists with detection, investigation (when appropriate), intervention, and prevention of Elder abuse, neglect, and exploitation.
• Follow-up with the elderly person to ensure resolution of concerns, and that situations have improved.
• Provide a brief client summary report during designated EPT meetings. It is suggested that all members use a standard case summary form. EPT members will complete and submit case summary forms to the EPT Coordinator for review prior to the meeting.
• Provide support and assistance to other EPT members.

The Native American Housing Assistance and Self Determination Act of 1996 (NAHASDA) PL104-330 became a law on January 3, 1996, and is the governing statute of the Office of Native American Programs (ONAP). The goal is to provide federal assistance for Native American tribes in a manner that recognizes the right of tribal self-governance.

Regulations for NAHASDA, which are negotiated with tribes after each reauthorization of the statue, can be found in the Code of Federal Regulations at 24 CFR Part 1000. HUD’s Office of Public and Indian Housing issues notices to articulate regulations in more detail. Notices are reviewed and approved by HUD’s Office of General Counsel. HUD’s ONAP issues program guidance, which are less formal interpretations of a regulation and are not vetted by the Office of General Counsel.

HUD Assisted Housing Program

HUD develops income limits based on Median Family Income estimates and Fair Market Rent area definitions. These income limits determine eligibility for assisted housing programs including:

• Public housing
• Section 8, project-based
• Section 8, housing choice voucher
• Section 202, housing for the elderly
• Section 811, housing for persons with disabilities programs

Tribal HUD Training

HUD’s office of Native American Programs sponsors several tuition free trainings and workshops for Tribal leaders, Tribal housing staff, board members, housing professionals, and community and nonprofit partners.

Some examples of trainings include:

• Indian housing plan
• Procurement
• Capacity
• Construction
• Crime prevention
• Tax credit and Title VI

Available Programs

The ONAP administers the following six programs available to American Indian/Alaska Native/Native Hawaiian (AI/AN/NH):

1. Indian Housing Block Grant (IHBG)
   NAHASDA gave tribal governments’ greater control over the housing program by consolidating a number of federal housing programs that provided funding primarily to low-income Native Americans, into a single, formula driven recurring block grant program. Under the Indian Housing Block Grant, tribes self-determine the plan, design, construction and maintenance of affordable housing on Indian reservations and in Native communities
2. Section 184 Indian Home Loan Guarantee Program (IHLGP)
   The IHLGP was created to help increase Native access to homeownership by providing a guarantee to lenders on mortgage loans made to Native borrowers. Section 184 loans can be used, both on and off Native land, and for construction, rehabilitation, refinance, or purchase of an existing home
3. Indian Community Development Block Grant (ICDBG)
   The ICDBG provides single purpose grants for housing rehabilitation, land acquisition, community facilities, infrastructure construction, and economic development activities that benefit primarily low and moderate income persons
4. Title VI Loan Guarantee Program
   Authorized under NAHASDA, the Title VI Loan Guarantee Program assists IHBG recipients (borrowers) who want to finance grant-eligible construction or development activities such as: creating new housing, rehabilitating housing, building infrastructure, community facilities, acquiring land to be used for housing, or preparing architectural and engineering plans. Tribes may use a variety of funding sources in combination with Title VI financing
5. Native Hawaiian Housing Block Grant
   NAHASDA was amended in 2000 to add Title VIII- Housing Assistance for Native Hawaiians. This is a similar program to the IHBG, but for Native Hawaiians who reside on Hawaiian Home Lands
6. Section 184A Native Hawaiian Home Loan Guarantee
   The Section 184A program provides access to sources of private financing for home ownership, property rehabilitation, and new construction opportunities for eligible Native Hawaiian Individuals and Families. These loans are limited to owner-occupant single family dwellings located on Hawaiian home lands

National Tribal Housing Directory

For more information, contact your area ONAP office in:

• Alaska – (907) 677-9836
• Eastern Woodlands – (800) 735-3239
• Hawaii – (808) 457-4662
• Northern Plains – (303) 672-5465
• Northwest – (808) 457-4674
• Southern Plains – (405) 609-8520
• Southwest – (602) 379-7200

Resources

• U.S. Department of Housing and Urban Development. (2017). Resources for Tribal Housing & TDHEs.

Various professional disciplines are represented on the Tribal Elder Protection Team (EPT), one of which is law enforcement. This page defines the roles and responsibilities of a law enforcement officer EPT member. This representative is designated as the main contact for law enforcement services. You may want to recruit this representative from your local tribal law enforcement agency or choose a Bureau of Indian Affairs (BIA) agent or a federal or state official. Recruit officers who have a vested interest in Elder case investigations. The law enforcement officer roles include but are not limited to:

• Being a designated representative from the agency who participates in regular EPT meetings or arranges for an alternate when the representative is unavailable.
• Providing information about the EPT to his/her agency staff to increase awareness and referrals.
• Responding to crisis situations. Each team member may be assigned “on-call” duties during nights and weekends and can make and accept referrals to the EPT.
• Coordinating medical and emergency response to Elder abuse, neglect, and exploitation situations.
• Making client referrals to the EPT for collaboration of additional community services essential to the well-being of an elderly person.
• Sharing client information with the EPT, when appropriate.
• Collaborating with EPT representatives to detect, investigate, intervene, and prevent additional abuse and help minimize further trauma to the Elder.
• Providing expert input of reviewed cases and follows up with the elderly persons to ensure resolution of concerns and that situations have improved.
• Providing a brief client summary report during designated EPT meetings.
  • All members should use a standard case summary form, which they will complete and submit to the EPT coordinator for review prior to meetings.
• Providing support and validation/assistance to other EPT members.

Abuse may make it harder for an older person to stand up for his/her rights. It is often more difficult for people to disclose abuse by relatives and friends than abuse by strangers. People who have been victims of Elder abuse, neglect, and exploitation may be unwilling to report the abuse or have the abusers prosecuted. The victims may:

• Believe the abuse is their fault
• Be ashamed that their children/partner are harming them
• Be dependent on the abuser for income and social networks
• Fear legal punishment
• Worry about losing their family
• Fear retribution or revenge from the abuser
• Worry about having to rebuild their finances if they leave the situation

These issues must be taken into account when responding to reports of Elder abuse. It is important to be mindful that cultural factors may affect perceptions of Elder abuse and approaches to problem solving among people from culturally and linguistically diverse communities.

All federally recognized Indian tribes that do not reside in states governed by Public Law 280 [67 Stat. 588 (1953)] are required to maintain a three-pronged (executive, legislative, and judicial) democratic government. This includes a law enforcement agency as part of its judicial arm. Indian reservations located in states governed by Public Law 280 are usually policed by local city or county law enforcement agencies and are required to have a democratic government in place. The type of crime often determines who has criminal jurisdiction. Most tribal police departments have jurisdiction only over misdemeanors and ordinances found in the tribal code. Felonies fall under the jurisdiction of either the BIA Law Enforcement Services or the Federal Bureau of Investigation (FBI).

Tribal codes authorize law enforcement to perform certain duties within the boundaries of the reservation. These duties include responding to calls for service, enforcing tribal laws and ordinances, and maintaining order on the reservation. Power is vested in law enforcement by the members of the tribal community. When tribal members observe officers acting in a positive, unbiased manner, the officers earn the trust and confidence of the community. When this is accomplished, they become more respected and accepted by the majority of the tribal members.

Most descriptions of law enforcement in Indian Country indicate a rural working environment with rural-style policing. Many tribal communities operate with no more than three officers and as few as one officer on duty at any given time. Tribal communities have a government-to-government relationship with the U.S. They have significantly more scope for policy-making than individual U.S. cities or states. Tribal nations adopt constitutions, write civil and criminal laws to regulate conduct within their territorial boundaries, and enforce these laws with their own judicial systems.

Departments in Indian Country face these challenges with a limited resource base. Existing data suggest that tribes have between 55% and 75% of the resource base that is available to non-Native communities. This disparity may stem from the unique culture, geography, and economics on Native American reservations, such as: limited administrative and technological resources available to tribal police departments, inadequate coordination between tribal and federal agencies, and management problems common to tribal and BIA police departments. These disparities create a crisis in reservation policing.

The experience and research on community policing is congruent with the findings on effective governing institutions in Indian Country. Community policing provides a framework that tribes can use to design and implement new Native approaches to policing. These approaches help align police priorities and values with those of the community, improve the quality of policing in Indian Country, and strengthen the tribe as a whole.

Operation Golden Shield

Operation Golden Shield is a voluntary program. It has successfully provided protection and prevention of Elder abuse and neglect through the Anadarko Agency. Officers make random, friendly visits to vulnerable adults in response to the growing concerns of Elder abuse and neglect. Initially, 27 vulnerable Elders received a friendly visit from officers. In order to accomplish this task, each officer made three to four Elder visits per shift. If Elder abuse was suspected, the officer reported back to the BIA Law Enforcement Agency office and then enlist Tribal Social Services for assessment.

Interviewing Victims: Special Concerns When Interviewing Older Victims

1. Interviewing older victims requires special care and patience. Simple measures can help the victim feel less anxious. Always treat the person with respect. Ask permission to enter the home or to be seated, and ask the elderly person if he/she is fluent in English or if he/she would be more comfortable with a translator. Other strategies include:
   1. Indicating immediately that you are there to help.
   2. Speaking slowly and clearly and being patient while waiting for a response.
   3. Keeping your weapon out of sight. Depending on the situation, a weapon can be frightening for the elderly.
   4. Addressing the victim by name, but do not use the person’s first name. This is considered disrespectful by many elderly persons.
2. Conduct a structured interview using predetermined questions. This is a way to obtain the facts needed to proceed with the case.
3. If the person is having difficulty remembering when an event occurred, offer memory cues.
   For example, “At the time of the event, what television program was on?”
4. For hearing impaired persons, eliminate as much background noise as possible and use visual cues. Ask if the person is having difficulty hearing and whether he or she has a hearing aid that would help. Written communication can be used too.
5. Some visually impaired people may not look directly at you because they see better in their peripheral zones.
   1. Within the Native American culture, it is a common practice to not maintain eye contact. Averting the eyes is a sign of respect.
6. Inform the victim about what to expect during the investigation.
7. Minimize the number of interviews and the number of people present.
8. Allow the victim to describe the incident in his/her own words.
9. Be patient and reassuring. Some older people, particularly, those in crisis, may need time to collect their thoughts and to take frequent breaks.
10. Avoid unnecessary pressure.
11. Acknowledge the victim’s anxiety, and try to discern its cause.
    For example, “You seem nervous. Would you tell me what is making you nervous?”
12. Keep it simple. Phrase questions in a clear, concise fashion.
    For example, “Please tell me how you were injured.”
13. Keep questions short. Do not ask leading or multi-pronged questions.
    An example of how NOT to ask a question: “The disrespect by your son is so bad you would rather be placed in a home for the elderly, right?” Instead, ask, “What do you want to happen for you to have a safer life?”
14. Ask open-ended questions that encourage further discussion.
    For example, “What happens when your grandson comes over when he is drinking alcohol?”
15. Accept and use the victim’s terminology and language for acts, body parts, etc.
    1. When asked directly, many Native Elders will not indicate that they have experienced abuse or neglect, but when the terms “disrespect” or “bothering” are used, many Elders will discuss incidents that can be abusive acts.
16. Avoid influencing the victims account of the alleged offense.
17. Even if the victim appears to be somewhat confused, do not discount the information.
18. Make every effort to obtain the fullest possible response before relying on information from others.
19. If you need another person to assist in communicating or providing information for the victim, conduct the conversation in the victim’s presence and look for signs of corroboration from the victim.
    For example, nodding in agreement. Do not discuss the victim as if he/she is not in the room.
20. Do not discount a complaint because the victim is unwilling to cooperate.
21. Do not argue with the victim.
22. Assess the likelihood of retaliation. If a threat is present, arrange for protection.
23. Determine whom the victim first told about the abuse/neglect/exploitation.
24. Show the victim records or other documents that suggest abuse. Note his/her response to each record or document that is in dispute.
25. Conclude the interview in a way that makes the victim feel free to contact the investigator again.
26. Ensure that the victim is capable and has the means for contact. If not, take measures to facilitate follow-up with the victim.
27. Determine whether the witnesses are likely to be intimidated, made to feel guilty, or threatened with reprisal for providing testimony.
28. Encourage ongoing training about optimal team functioning, including process performance.
29. Encourage skill building for responding to emotionally charged situations.

Content for this document was contributed by Royleen Ross, PhD, and Iva Grey Wolf, PhD.

Resources

• Bureau of Justice Statistics, U.S. Department of Justice. (2017, July). Tribal Crime Data Collection Activities, 2017.
• Wakeling, S., Jorgensen, M., Michaelson, S., & Begay, M. (2001). Policing on American Indian Reservations. National Institute of Justice, U.S. Department of Justice, Washington, D.C. September.
• U.S. Department of the Interior Bureau of Indian Affairs, Office of Indian Services, Division of Human Services (2013). Adult Protective Services Handbook: A Guide for Protecting Vulnerable Adult and Elder Indians from Abuse, Neglect, and Exploitation.
• Baker-Demaray, T. B. (2009). Perceptions of Elder Abuse Among Native American Seniors (Master’s Thesis, University of North Dakota).

As a member of the Elder Protection Team (EPT), this representative is designated as the main contact for any medical referral. This representative may be a physician, a licensed nurse, an emergency medical technician, or any other medical service staff member. This team member acknowledges this responsibility to be available to assist the elderly patient or will arrange for an alternate EPT attendee when they are unavailable. The Medical Service Representative roles include, but are not limited to:

• Providing a designated representative from their agency to participate in regular EPT meetings, or will arrange for an alternate when unavailable.
• Providing information about the EPT to their agency staff to increase awareness and referrals.
• Making client referrals to the EPT for collaboration with additional community services essential to the well-being of an elderly patient.
• Sharing patient information to the EPT, when appropriate.
• Collaborating with EPT representatives to detect, investigate, intervene, and prevent additional abuse.
• Minimizing further trauma to the elderly patient by conducting regular Elder abuse safety screenings/assessments when the elderly person is attending a scheduled medical appointment.
• Providing expert input and review of cases and providing appropriate follow-up for the elderly patient. Depending on your facility, you may need to contact your compliance officer prior to providing input to the EPT.

Implement a Safety Screening

Elderly safety screening procedures are implemented in various medical office settings. Each office may have their own set of procedures and practices for conducting an elderly safety screening. While there is no “right” way to implement the screening, an annual safety screening should be conducted. Before your medical office implements a screening protocol, make sure to call your local Area Agency on Aging, Adult Protective Services office, or a Title VI program to ensure you have the appropriate contact information if you need to refer a patient. Implement the following during a safely screening:

• Screening should be done by a physician or triage nurse
• Screening takes place at least once a year during a non-emergency medical visit
• Prior to the appointment, staff should place an Elder abuse screening assessment form within the screening packet for each elderly patient
• Screening document should be placed in the patient’s chart, and given to the elderly patient while they wait for the physician in the exam room
• The screening should be conducted in a confidential setting outside the presence of the elderly patient’s family, caregiver, or the person who brings the elderly patient to their appointment
  • Be sure the caregiver or family member is not completing the screening form
• When the physician arrives, the screening results are reviewed with the elderly patient during the appointment
  • Have staff members assist with referrals when necessary
• The completed screening becomes part of the patient’s medical records

If your patient may be cognitively impaired or have dementia, you will need to consider your responsibilities under state or tribal laws to report Elder abuse to Adult Protective Services or appropriate victim’s services agency in your tribal community. This may also require staff assistance for the completion of the screening form, rather than a caregiver or family member.

Elder Abuse Screening Instruments

Workers need to be aware of warning signs that Elder abuse may be occurring, and learn to identify signs of abuse. Screening instruments do not confirm Elder abuse. They are tools to assist the worker in determining the need for more assessments or if a referral to Adult Protective Services or appropriate Victim’s Services agency in your tribal community may be required. A few examples of Elder abuse screening instruments include:

• The Hwalek-Sengstock Elder Abuse Screening Test (H-S/East): A 15-item screening device for service providers, to assist with identification of people at risk of abuse, and in need of protective services.
• The Elder Assessment Instrument: A 41-item assessment used in clinical settings to assess signs, symptoms, and subjective experiences of physical abuse, neglect, and exploitation. There is no resulting “score.”
• The Native Elder Life Scale (NELS): A instrument used to assess Elder mistreatment. Specifically developed from the H-S/EAST for American Indian and Alaskan Native Elders.
• Shielding American Indian Elders Interview protocol: A 41-page protocol document used during interviews with American Indian Elders. To gather general basic information about the Elder, along with questions about general health, the H-S/East, the Native Elder Life Scale (NELS), Conflict Tactics Scale, and items concerning the individual’s belief about the treatment of Elders.

Reporting Allegations of Abuse

Reporting Parties:

• Voluntary reporters (e.g., victim, family, friends, neighbors, others);
• Mandatory reporters (e.g., medical providers, first responders, clergy, behavioral health providers, and firefighters.
  • Any mandatory reporter who has reasonable cause to believe that any vulnerable adult with whom the official comes in contact, while acting in an official capacity, has suffered abuse shall report or cause a report to be made by immediately telephoning or by alternative methods to the local office of the Department of Human Services, Victims of Crimes office, or the local tribal law enforcement agency.
  • When a report of a possible crime is received by a department, the department shall notify the law enforcement agency having jurisdiction within the county where the report is made. The law enforcement agency shall confirm to the reporting department its receipt of the notification.

Physicians, psychologists, members of the clergy and attorneys are not required to report such information communicated by a person if the communication falls under client privilege (Consult your state and tribal government, as each have their own laws on mandated reporter requirements).

Required Information:

Reports of abuse must include the following information, if known:

• The name and address of the elderly person or vulnerable adult
• The name and address of any person(s) responsible for the care of the vulnerable adult
• The nature and extent of the abuse including any evidence of previous abuse
• The explanation given for the abuse
• Any information that led the person making the report to suspect that abuse has occurred
  Any other information which the person making the report believes might be helpful in establishing the cause of the abuse and the identity of the perpetrator
• The date of the incident
• The venue or location where the abuse occurred

Mandatory reporting statutes grant immunity to the professional who reports their suspicions in good faith, and the reporter often remains anonymous. Make sure to not label the reporting process as an investigation but as an attempt to gather information to determine what services might benefit the Elder.

Please contact your local attorney to determine the laws and rules applicable to your medical practice.

Resources

• University of Maine Center on Aging. (May 2, 2007). Elder abuse screening protocol for Physicians: lessons learned from the Maine partners for Elder protection pilot project.
• Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST).
• Elder Assessment Instrument
• Jervis, L. L., Fickenscher, A., Beals, J., & Shielding American Indian Elders Project Team. (2014). Assessment of Elder mistreatment in two American Indian samples: Psychometric characteristics of the HS-EAST and the Native Elder Life–Financial Exploitation and–Neglect measures. Journal of Applied Gerontology, 33(3), 336-356.
• Jervis, L.L, & Shielding American Indian Elders project team (Interview protocol). Shielding American Indian Elders (SAIE) Interview. University of Oklahoma, Norman Oklahoma. Funded by the National Institute on Aging.
• Department of Justice, Elder Justice Initiative (2017). Sample: Protocol- Clackamas.

Various professional disciplines are represented on the Elder Protection Team (EPT), one of which is the Adult Protection Services (APS) team member. Every state has an APS Department, but not all tribal communities have suspected reports of Elder abuse are reported, while other tribes may rely on an Elderly Protection Program to conduct investigations. Finally, some tribes may not have a designated office to report suspected cases of Elder abuse. Reports then fall to the tribal law enforcement department.

Adult Protective Services Definition

Adult Protective Services is “a social services program provided by state and local government nationwide serving older persons and adults with disabilities who are in need of assistance due to abuse, neglect, self-neglect and/or exploitation.”

The Tribal Adult Protective Service Representative Role

• Provides a designated representative from their agency to participate in regular EPT meetings, or will arrange for an alternate when unavailable.
• Provides information about the EPT to their agency staff to increase awareness and referrals.
• Makes client referrals to the EPT, when appropriate for the coordination of additional Elder services.
• Shares appropriate client information to the EPT.
• Collaborates with EPT representatives to detect, investigate, intervene, and prevent additional abuse, neglect, and exploitation.
• Provides expert input, review of cases, and provides appropriate follow-up.
• Conducts case investigation and intervention, when appropriate.
• Acts as a liaison between the EPT and the APS agency.

Eligibility for Adult Protective Services in Indian Country

An individual must meet the basic requirements:

• Residing in designated service areas
  • Abuse that occurs on tribal land may be subject to tribal jurisdiction, based on whether the abuser and victim are American Indians
  • Federal law will apply to severe crimes regardless of where the crime took place
• Enrolled member of a federally-recognized tribe
• Over the age of 18 years and disabled, or an elderly person

Age for consideration may vary from tribe-to-tribe, but usually persons aged 55 years or older are considered elderly in some tribes.

Services

Services are provided for vulnerable adults and elderly persons when they are:

• Deprived temporarily or permanently of needed supervision by responsible adults
• Being neglected, abused, or exploited
• Needing services when they are mentally or physically handicapped or otherwise disabled
• Requiring assistance to manage their Individual Indian Money or other financial accounts

Cooperation with Court Systems

Adult protective services provide cooperation with relevant court systems to make interventions and coordinate services to the elderly person including but not limited to any of the following:

• Coordinating with tribal courts system to provide services to investigate and provide documentation on allegations of abuse, neglect, and exploitation
• Coordination of other local services, such as community organizations, elderly services agencies, and facilities in the tribal community
• Coordinating with law enforcement and tribal courts to place the victim of suspected abuse out of the home to assure safety while the allegations are being investigated
  • It is preferred that the elderly person remains in their home (when possible), and the suspected offender be removed while the investigation takes place
• Working with other community agencies to identify and help clients to use services available for assistance

National Adult Protective Service Association (NAPSA): Guiding Principles and Practice Guidelines:

The APS Representative should also follow the APS Guiding Principles and the NAPSA Practice Guidelines when developing a plan of action to address the identified needs and risks of the adult. The APS program is guided by Practice Guidelines that emphasize the need to:

• Recognize that the interests of the vulnerable adult are the first concern of any intervention
• Avoid imposing personal values on others
• Seek informed consent from the vulnerable adult before providing services
• Respect the vulnerable adult’s right to keep personal information confidential
• Recognize client differences such as cultural, historical, and personal values
• Honor the rights of the vulnerable adult to receive information about their choices and options in a form or manner that they can understand
• To the best of the worker’s ability, involve the vulnerable adult as much as possible in developing the service plan
• Focus on case planning that maximizes the vulnerable adult’s independence and choice to the extent possible based on the vulnerable adult’s capacity
• Use the least restrictive services and community-based services first, rather than institutionally based services whenever possible
• Use family and informal support systems first as long as this is in the best interest of the adult
• Maintain clear and appropriate professional boundaries
• In the absence of a vulnerable adult’s expressed wishes, support casework actions that are in the older adult’s best interest
• Use substituted judgment in case planning when historical knowledge of the older adult’s values is available
  • Substituted judgment is information regarding the patients’ wishes from significant others, for their preferences for life support, drug therapy, fluid infusions, or supplemental nutrition distinguished from a decision based on an advance directive. Substituted judgments are relied upon when patients are unable to advocate for themselves, and are generally respected by healthcare workers
• Do no harm. Inadequate or inappropriate intervention may be worse than no intervention

APS Report Documentation Procedures

APS programs have a systematic method of documenting the entire case process. When completing case documentation, the APS worker:

• Values the importance of clear, concise, accurate and fact-based case documentation and reporting, and its long-term impact on the client and other involved parties
• Values accuracy, objectivity, and unbiased documentation of diverse cultures, lifestyles, and needs case recording and preparation of reports
• Respects and acknowledges the time frames necessary for the preparation and submission of case documentation and reports to the supervisor, to allow sufficient time for review and in conformance with mandated timelines for completion of required tasks
• Clearly supports the case finding
• Includes a confidentiality statement per the programs rules and regulation

APS Guiding Principles:

• Respect the integrity and authority of victims to make their own life choices
• Hold perpetrators, not victims, accountable for the abuse and for stopping their behavior
• Avoid victim blaming questions and statements
• Take into consideration the victims’ concepts of what safety and quality of life means
• Recognize resilience. Honor the strategies that victims have used in the past to protect themselves
• Redefine success. Success is defined by the victim, not by what professionals think is right or safe

Resources

• National Adult Protective Service Association, (2013). Adult protective services: recommended minimum program standards.
• U.S. Department of the Interior Bureau of Indian Affairs, Office of Indian Services, Division of Human Services (2013). Adult Protective Services Handbook: A Guide for Protecting Vulnerable Adult and Elder Indians from Abuse, Neglect, and Exploitation.
• Substituted judgment. (n.d.) Medical Dictionary. (2009).
• Hwalek, M. “Proper Documentation: A Key Topic in Training Programs for Elder Abuse Workers” Journal of Elder Abuse & Neglect, Vol 1(3) 1989.
• Tribal STAR Program. (undated resource). Recommendations for developing and maintaining tribal relationships.
• Garcia, M.A. and Tehee, M. (2014). Commentary on the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct. Society of Indian Psychologists, Albuquerque, NM.

As a member of the Elder Protection Team (EPT), this representative is designated as the main contact for any social service need. There may be one or more depending upon the services available. This team member is available to assist the elderly person, or will arrange for an alternate when they are unavailable. The Social Worker’s roles include, but is not limited to:

1. Responding to crisis situations, as each team member can be assigned “on-call” duties during nights and weekends, and will make and accept referrals to the EPT.
2. Coordinate medical and community response to Elder abuse, and assist in collaboration of additional agencies the client may need to utilize.
3. Assessing the Elder’s needs, living situations, individual strengths, and support networks to help determine goals.
4. Referring clients to community resources, such as nutrition programs, housing, and healthcare.
5. Advocating for, and helping clients work with agencies to apply for and receive benefits.
6. Assisting with detection, investigation (when appropriate), intervention and prevention of Elder abuse, neglect, and exploitation.
7. Following-up with Elders to ensure resolution of concerns, and that situations have improved.
8. Providing a brief client summary for each client during designated EPT meetings. It is suggested that all EPT members use a standard case summary form. EPT members will complete and submit case summary forms to the EPT Coordinator for review prior to meeting.
9. Providing support and validation/assistance to other EPT members.

Information to Collect in a Comprehensive Assessment:

Social Workers should ask the client about their typical day-to-day activities, in a natural way, to pick-up cues about how the Elder is being treated by family members, friends, or other caregivers.

Client Information:

• Age-requirement eligibility for services and other available resources
• Marital status: single, married, widowed, divorced, partnered
• Education: highest grade completed, language comprehension, reading and writing capability
• History: birthplace, family size and members, social roles, work history, significant historical life events and significant people

Functioning:

• Determine if the client is independent or in need of assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs).
  • ADLs are basic care tasks: bathing, dressing, toileting, and self-feeding
  • IADLs are related to maintenance of an independent household: transportation, shopping, preparation of meals, housework, financial management, and use of telephone
• Determine who assists the client with functioning needs. For example: identify if the client can drive, has access to a car, relies on family/friends for transportation, or has access to public transportation
• Identify any assistive device(s) the Elder uses to enhance their mobility (e.g., wheelchair, cane, or walker)

Legal:

Factors such as confusion around finances, social isolation, cognitive impairment, and a recent loss of a loved one can increase an Elder’s risk of abuse. In addition to these characteristics, social workers should collect the following information:

• Identify who is in charge of the Elder’s financial affairs.
• Identify any current services in place, and the Elder’s eligibility for linkage to services (such as Medicare, or home and community-based services).
• Ask if the Elder has a durable power of attorney for financial affairs, healthcare decision-making and/or advanced directives of any kind.
• Establish who has been named to make decisions when the Elder is no longer capable.

In relation to advanced directives, determine if the client made any decisions regarding medical intervention, where they want to pass in peace (at home, hospice, hospital), and who is designated to carry out the Elder’s wishes.

Physical Environment:

Social workers can learn a lot about the Elder and their abilities from how the living spaces are arranged. A decrease in mobility can lead to an increased risk of Elder abuse and neglect. In the assessment you are looking for potential risks for falls (e.g., a loose floor rug). The physical location of the client within the home may also indicate risk for abuse, neglect, or self-neglect.

• Has the Elder reduced or miniaturized their living spaces to incorporate/accommodate a lack of mobility?
• Have items from the bedroom been moved into the living room to maintain control over household tasks?
• Is there a calendar on the wall which is current and up to date?
• Is there a clock which is set to the proper time?
• Is there a smell of urine or do you notice urine stains?

Physical Health:

The assessment of issues related to physical and psychological health is important because of the interconnection between health and other aspects of well-being. The Elder’s answers to these questions can alert the social worker to possible abuse, neglect, or self-neglect. The following are a few examples of topics that Social Workers would cover as part of a physical health assessment. The list is not exhaustive.

• Self-rating of health: The Elder’s opinion of their health gives the Social Worker insight into how the elderly person has adapted to medical conditions, and determines if what is being reported is consistent with what is observed.
• Medical history: Some of this history will help the Social Worker gain a sense of whether or not unexplained injuries may be related to medical or treatment conditions, or if a caregiver is neglecting the need for regular medical care.
• In the medical history, assess:
  • Current and past medical problems
  • Occurrence of injuries and/or hospitalizations
  • Emergency room visits (reason and frequency)
  • If there is a primary care physician
• Medication use: The Social Worker needs to assess for correct and regular usage of prescribed medications. Caregivers or elderly persons may neglect to administer medication as needed.
• Incontinence: Many elderly persons are embarrassed to discuss this issue, but managing bladder and bowel functions is essential to the maintenance of independent living.
  • If a caregiver neglects to properly assist the Elder, physical and psychological harm can result. The Social Worker can act as an advocate in helping the Elder to understand that incontinence is not an inevitable part of the aging process and can be treated
• Use of alcohol and other substances: Ask about current and past use. Do not assume that an elderly person does not use recreational drugs. When assessing alcohol use, be specific about type of alcohol (beer, wine), quantity (two beers), and size (a 6 oz. glass of wine). Alcohol and drug abuse can contribute to poor health and loss of functioning in the Elder, and is linked to self-neglect.
• Nutrition, diet, and exercise: Adequate nutrition and exercise are important in maintaining physical and psychological health. Find out how often the Elder eats and what the diet consists of. Many factors can contribute to loss of interest in food, such as medications, poorly fitting dentures, and loneliness.

Psychological Health:

The National Center on Elder Abuse (NCEA) reports that Elders living with dementia are at a greater risk for abuse than those without. A 2010 study found that 47% of participants with dementia were abused by their caregivers. Social workers should assess the caregiver’s mental and emotional status as well as the availability of support.

Examples of information typically collected include:

• Personality: Determine how the Elder views the world and coping strategies.
• Cognition or mental status: While not appropriate for all older adults or across cultures, the Mini Mental State Examination is commonly used. It may need to be adapted culturally for a better assessment of the elderly person.
• Emotional well-being: Look for signs of possible depression and thoughts of suicide. Elderly persons may exhibit anxious behaviors as well, but a relatively small percentage have diagnosed anxiety disorders, so careful assessment of symptoms is important. Because elderly person are at a higher risk for cognitive impairment, it is essential Social Workers perform a capacity assessment.

Social Supports:

Inadequate social support and social isolation are risk factors for abuse, neglect, and exploitation. It is important to get a good sense of who is in the Elder’s social network. The social worker should ask about:

• Quality and frequency of contacts/events attended (e.g., has there been a decline recently, if so, why?)
• Family, companions, friends, neighbors, religious organization, clubs, and access to a senior center
• Instrumental supports (formal and informal caregivers)
• Social roles (grandparent, volunteer, mentor)
• Employment (full or part-time, what type of work, self-satisfaction, financial need)
• Activities, hobbies, sports/entertainment
• Where or with whom the client seeks comfort
• Who the client would call in the event of an emergency, besides 911

Resources

• Council on Social Work Education (2015). Elder Justice Curriculum Modules for MSW Programs.
• Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W. (2010). Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 58(3), 493-500.
• Mini-Mental State Examination (MMSE) (2012). Link no longer available online.

To make sure an Elder Protection Team (EPT) is managed appropriately, and to increase accountability of team members, it is recommended to designate an EPT Coordinator or Director. This individual may have dual roles on the EPT as the coordinator, and as a representative for a tribal agency (e.g. Title VI Director). This team member has an important role on the EPT. They will facilitate a group of professional community members in the unification of collaborative efforts to assist Elders who may be experiencing Elder abuse, neglect, and exploitation. Some tribes may choose to have a coordinator and a director to share the responsibilities and work load. For many Tribal EPTs, the director of an Elderly Services Program will serve as the EPT Coordinator. Each EPT is as different as the tribal communities in which they serve. A EPT Coordinator is primarily responsible for administrative tasks, which may include:

• Coordinating team membership
• Sending meeting alerts
• Creating the meeting agenda
• Setting up the meeting room
• Recording meeting minutes
• Receiving and reviewing completed case summaries
• Gathering of Elder information
• Facilitating discussions among team members
• Arranging trainings and agency overviews
• Case follow-up and client tracking
• EPT meeting follow-up

The Tribal EPT Coordinator’s Role

1. The EPT Coordinator is responsible for enhancing communication between tribal agencies and programs; more specifically:
   1. Scheduling meetings and follow-up with reminders
   2. Coordinating with all case presenters in the week prior to each meeting and ensure that representatives involved in the case are prepared for the meeting
   3. Suppling EPT representatives with approved forms for documentation
   4. Developing a sign-in sheet to be used on the day of each meeting
   5. Recording meeting minutes using an approved method of information collection (audio recording devices, or a paper document form)
   6. Coordinating food and drink for meetings/events
   7. Facilitating discussions during meetings
   8. After meetings, following-up with presented cases in a timely manner to ensure resolution of client concerns, and ensuring the Elders’ needs are being addressed
2. The EPT Coordinator insures that confidentiality agreements are maintained and rules are followed by all EPT representatives. All collaborating agencies will sign a Memorandum of Understanding (MOU) with the EPT. The MOU will clearly state the agency representative’s responsibilities and privileges. EPT participants who are not regular representatives from the collaborating agency will sign a monthly confidentiality agreement at the EPT meeting (this can happen when an alternate for a regular EPT representative is needed). The MOU should include:
   1. Length of commitment (e.g., 2-year rotation of selected agency representatives)
   2. Time commitment, including meeting times and any other travel
   3. Mandatory meeting requirements
   4. Confidentiality requirements
   5. EPT training requirements
   6. Participation requirements for EPT evaluation, and
   7. Case summary submission requirements for case presentations
3. Each team member, including the EPT Coordinator, can be assigned “on-call” duties during nights and weekends to respond to crisis situations. “On-call” EPT members will manage and coordinate client intake procedures, such as:
   1. Responding to emergency personnel to assist an Elder in need of EPT interventions
   2. Coordinating community services available to an Elder
   3. Managing daily functions of the EPT
   4. Reviewing case summaries prior to EPT meetings
4. The EPT Coordinator assists and supports team members, helps organize case summaries presented at meetings, and encourages the involvement of interagency assistance for team members. With the creation of the EPT, the coordinator works to increase appropriate team membership and improve attendance from team member agencies. The coordinator, along with other team members, reach out to community partners who do not currently attend the EPT and invite them to attend.
5. The EPT Coordinator reviews confidentiality rules and discusses meeting ground rules to ensure a safe environment for group discussion of difficult cases, including situations where agencies disagree or where their mandates require differing approaches. EPT members will not permit the blame or public shaming of any member or participant. Most importantly, the coordinator will manage interpersonal dynamics among team members to insure appropriate communication, and for conflict resolution.
6. At the start of each meeting, the EPT Coordinator facilitates member “check-ins” addressing issues or resolution of previous meeting client discussions. The coordinator checks in regularly with all team members to ensure that EPT needs and expectations are being met. The coordinator continues to outreach to agencies/programs for commitments of support for the EPT, and building collaboration with all tribal programs. The coordinator will also be responsible for orienting new team participants from agencies by providing them with an EPT fact sheet and answering any questions that may arise.
7. Additional activities may include but are not limited to:
   1. Removal of any identifying information of Elders before EPT meetings
   2. Collecting and shredding meeting case summaries and other documents as necessary to maintain confidentiality procedures
   3. Arranging for team trainings to facilitate professional development for team members
   4. Gathering community feedback on the effectiveness of the EPT within the tribal community
   5. Presenting information about the EPT roles and functions to the tribal council and other community members, and
   6. Representing the EPT at community meetings, gatherings, and other events

Some tribal communities are able to hire a full-time EPT Coordinator as they may have funding to sustain this position, where other tribal communities many not have funds available. In these cases, this would require a highly motivated individual who would volunteer their time to this position.

Resources

• Center of Excellence on Elder Abuse & Neglect, Human Service Department, County of Sonoma (2012). A collaborative approach to multidisciplinary teams in Sonoma County.
• Department of Justice, Elder Justice Initiative (2017). Chapter 3: selecting team members.
• Department of Justice, Elder Justice Initiative (2017). Chapter 6: MDT coordinator.
• Content for this document was adapted from correspondence with Wilson Wewa of the Confederated Tribes of Warm Springs from November 2016 through May 2017.
• The Confederated Tribes of Warm Springs, Wilson Wewa (2014).
• The Confederated Tribes of Warm Springs, Wilson Wewa (2014). Multidisciplinary Team Approach on Elder Abuse.

Additional considerations during implementation.

• Determine how often should the code(s) should be reviewed, to ensure that it continues to protect the Elders from abuse.
• Develop a Tribal Elder Protection Team
• Create a plan for evaluation. Determine a process for recording data from Elder abuse incidents. Evaluation data will be helpful in determining the effectiveness of the code(s) and in providing
• justification in grant applications for funding of Elder abuse programming.
• Continuing education, and building awareness about Elder abuse in the community for health providers, service providers, law enforcement, and community members.
  • NAEJI’s Online Interactive Educational Sections

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

Code(s) must include policies and procedures that clearly identify authorized key agencies in each phase, stages in reporting and investigations, timelines, and penalties. Protocol should include:

• Designated agency(ies) for receiving reports, reporting procedures, protection of reporters, intake, assessment, casework activities, case closure, follow-up, confidentiality, access to records, access to victims, and referral procedures.

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

The final draft should be presented to your tribal council or governing body for approval. If the code is not approved, the working group should decide what needs to be changed in the document based upon the concerns or suggested changes identified by the council or governing body. A revised draft can then be resubmitted for review from the tribal council or governing body for approval. Endorsement by an Elder group can help in advocating for the adoption of the code.

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

From the working group, select a task group to draft your Elder abuse and protection code including tribal values and areas of concern from collected data.

• Civil and Criminal Model Elder Abuse codes can be found on the NAEJI website.

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

Identifying tribal values held by the community members will guide all who use the code such as; tribal leaders, tribal members, service providers, police, and the court. When Elder abuse codes are being established always involve tribal Elders.

• Identify how the community deals with negative unwanted behaviors or actions.
• Discussion of the current approaches will prevent that behavior or action from occurring in the future.

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

Gathering information about Elder abuse to ensure understanding on the areas of concern in your community.

• Collect data from elderly programs, police, hospitals, health centers, and tribal social service providers.
• Establish regular meetings at the community or elder center and invite tribal members to discuss the importance of creating an Elder protection code(s).
• Conduct formal or informal surveys to identify Elder abuse issues. Distribute surveys to places where community members frequently gather.
• Gain a clear understanding of current laws in the community related to Elder protections.

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

The working group is tasked with gathering community information to identify the areas of concern to be addressed, including “who, what, where, when and how”. Always involve both male and female tribal Elders when establishing the working group. The working group may choose to assign its members specific responsibilities such as; facilitator, organizer, cultural interpreters (Elders), and task groups. Additional working group members should include:

• Tribal leaders who have experience with tribal governance or the authority within tribal government
• Law enforcement, especially tribal officers if available
• Title VI Director, Elderly Services Coordinator, or aging services staff
• Indian Health Service representative, behavioral health provider, or another medical professional
• Financial service representative
• Spiritual leader or healers

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

The process of obtaining support of tribal government may vary from tribe-to-tribe. Gaining approval for the development of an Elder abuse code may range from an endorsement by the tribal leader to the passage of a resolution by the tribal council.

• If tribal resolution is needed, it is recommended that an Elder, or a tribal service program representative if an Elder is not available, present this document to the council.
• Determine the most effective method of obtaining tribal council approval. Important documentation may include background information, statistical support, and/or a real-life case examples.
• Identify the length of time needed for tribal approval. If tribal council would like data, determine the need to gather the information. Also consider if there may be a change in council coming soon (e.g., election year).

Resources

• National Indian Council On Aging, The Elder Abuse Task Force (2008). Using your tribal values to develop Elder protection code: A step-by-step guide for communities.
• Native American Elder Justice Initiative. Civil and criminal Elder protection code examples.
• Native American Elder Justice Initiative.  Online Interactive Educational Sections.

Elder Protection Teams (EPTs) generally appear to have similar challenges that prevent the best outcomes for Elders and the EPT. Service agencies struggle to provide help to clients in the face of dwindling funding and resources, and staff members may feel that utilizing the EPT creates an additional burden. Some barriers to service that EPTs face include:

• Attendance issues (e.g., not having a large variety of agencies represented), lack of commitment from representatives to attend meetings regularly, lack of cases presented
• A lack of knowledge of other agencies’ policies and mandates, that often leads to a negative perception that some agencies are non-cooperative
• A frustration among agencies in dealing with seemingly unsolvable cases
• Maintenance of confidentiality
• Costs, travel time to meeting location, and
• Mandated reporter policies

Resources

• Content for this document was adapted from correspondence with Wilson Wewa of the Confederated Tribes of Warm Springs from November 2016 through May 2017.
• The Confederated Tribes of Warm Springs, Wilson Wewa (2014). Multidisciplinary Team Approach on Elder Abuse.

You will need to develop a sustainability plan.

• Must address how the Elder Protection Team (EPT) is funded
• Depending on the EPT, some tribes have funding to cover staff (e.g., EPT Coordinator) travel costs, and meeting per diems. Unfortunately, many tribal EPTs do not have funds to support paid staff, but it is recommended to employ at least one paid staff person to serve as the coordinator and conduct administrative duties. This may be part-time or a portion of the individual’s duties, depending upon the workload
• Another cost to consider is production and dissemination of meeting materials
• Tribes may designate a small percentage of civil and criminal penalties in cases involving Elder abuse to be used to build an Elder Justice fund, which can go to supporting the EPT

Resources

• Department of Justice, Elder Justice Initiative (2017). Chapter 3: selecting team members.
• Content for this document was adapted from correspondence with Wilson Wewa of the Confederated Tribes of Warm Springs from November 2016 through May 2017.

Program considerations include:

• Identify technical experience available to launch the Elder Protection Team (EPT) (e.g., computer resources)
• Determine if there are sufficient economic resources available
• Determine the legal requirements or restrictions for the EPT
• Develop a business plan and budget addressing how the EPT will operate. Some tribal communities run the EPT with minimal funds from one of the representative agencies, but most are
• coordinated on a volunteer basis

You will need to learn about the state and Tribal laws in your area.

• Is there a Tribal Adult Protective Services worker employed by the tribe?
• Does the tribe have a Victims of Crimes office?
• Is the tribe in a Public Law-280 state?
• Identify statues around law enforcement, elder care facility, guardianship and conservatorship, and mandatory reporting statues

If the tribe does not have codes established by the tribe, you will need to facilitate the development of a tribal Elder protection code.

Develop organizational rules for the Elder Protection Team (EPT):

• Who is the leader (e.g., EPT Coordinator)?
• Identify the goals of the EPT
• Develop protocols and documents needed to achieve the goals
• Establish written commitment from team members
• Develop EPT effective communication rules for any potential disagreements

Resources

• Center of Excellence on Elder Abuse & Neglect, Human Service Department, County of Sonoma (2012). A collaborative approach to multidisciplinary teams in Sonoma County.

Identify the tribal community’s concerns for the elderly through a Community Needs Assessment. A Community Needs Assessment should include:

• Definitions of Elder abuse and other related terms
• Elder abuse statistics (if available)
• Proposed solutions to how the Elder Protection Team (EPT) will respond to Elder abuse

Complete a Statement of Needs summary report, this document should present all of the findings from the Community Needs Assessment. This document should include a proposed response to any Elder abuse problems and clarify the areas of need to help address Elder abuse, neglect, and exploitation. The Statement of Needs Report is required for any grant proposal. Additional documents include:

• The goals of your EPT
• Drafting a grant proposal
• Gathering commitment from local authorities for the creation of an EPT
• EPT member recruitment
• Additional outreach and promotional materials to create awareness of the EPT

Resources

• Department of Justice, Elder Justice Initiative (2017). Chapter 3: selecting team members.
• Department of Justice, Elder Justice Initiative (2017). Chapter 6: MDT coordinator.

Things to consider when building your team:

• You may already have a group of individuals that share the same Elder concerns
• Make a list of all resources available to Elders in your tribal community
• Schedule a meeting with local professionals to discuss establishing a partnership between agencies to focus on Elder abuse, neglect, and exploitation.
• Learn what this team would want to accomplish
• What are the anticipated outcomes to developing an Elder Protection Team (EPT)?

Resources

• Center of Excellence on Elder Abuse & Neglect, Human Service Department, County of Sonoma (2012). A collaborative approach to multidisciplinary teams in Sonoma County.
• The Confederated Tribes of Warm Springs, Wilson Wewa (2014). Multidisciplinary Team Approach on Elder Abuse.

To build a solid foundation for your tribal Elder Protection Team (EPT), the EPT Coordinator will want to know what Elder service agencies are available in the tribal community. The creation of a tribal EPT will allow agencies to share the burden of investigating and efficiently responding to cases of Elder abuse in a timely manner. Team members can support each other’s roles, which decreases additional trauma to the Elder and allows them to continue as a valued and respected member of the tribal community. Elders benefit from EPTs by:

• Gaining access to coordinated services no matter how the Elder enters the system,
• Receiving concurrent services across multiple agencies specifically for the Elder’s needs,
• Increasing awareness of available services which improves access to all programs the Elder needs, and
• More positive outcomes for Elders through tribal agency collaboration.

Resources

• Center of Excellence on Elder Abuse & Neglect, Human Service Department, County of Sonoma (2012). A collaborative approach to multidisciplinary teams in Sonoma County.