Adult Protective Services & Mental Health: Practices and Policies
by Matti Robi & Ryan Doyloo, National Adult Protective Services Association
Across the country Adult Protective Services (APS) programs face added challenges in working with clients experiencing mental health concerns, particularly clients who have dual diagnoses. Proper training and robust services are needed for fully supporting clients with dual diagnoses but are not always present. Looking at current literature on practices and policies helps identify gaps and successes.
Practice Issues: Dual Diagnoses, Addiction, and Siloed Services
A person with dual diagnosis has both a mental disorder and an alcohol or drug addiction. These conditions occur together frequently. About half of people who have a mental disorder will also have a substance use disorder at some point in their lives and vice versa. The interactions of the two conditions can worsen both.
While common among APS clients, the literature regarding dual diagnoses and APS clients is limited. Generally speaking, the literature addresses issues related to singular diagnoses, and is limited in citing relationships between differing diagnoses and how this relationship affects APS work with the client. However, practice research can give insight into the different challenges that APS faces when attempting to provide services to clients who struggle with dual diagnoses, especially since APS is not traditionally structured to provide these services.
APS workers may have limited training on working with clients experiencing dual diagnoses (Ramsey-Klawsnik, 2015). One objective of APS workers is to assess the needs of clients and possible services to address and prevent abuse, neglect, or exploitation. Training to support an understanding of different mental health diagnoses and addiction issues and an understanding of the resources available through their local mental health system can help enhance services to clients. Clients experiencing addiction and substance abuse issues are also generally more likely to experience recurrence in APS, particularly when services are voluntary. Cases of recurrence amongst these clients are mostly seen in reports of self-neglect (Rowan et al., 2020). Training on techniques to encourage these clients to pursue treatment and their own goals, such as motivational interviewing, may help workers working with these clients.
A second challenge facing workers and clients who are dually diagnosed are systems that may not be well connected or are siloed. Siloed services may lead to clients experiencing recurrence in APS and can also contribute to APS being seen as a provider of mental health services. Generally speaking, mental health services are siloed when a client is not receiving treatment from a single provider or system, but rather these services are from multiple providers that do not run under the same system. Siloed services are common amongst various service providers but have been found to be most pronounced among physical and behavioral health services (Ewing and Tobler, 2014). This separation creates challenges for APS clients experiencing dual diagnoses. Successful mental health care is integrated; with this communication and coordination, clients are more likely to experience improvement in their mental health and quality of care. Overall, they report feeling that they are being treated as a “whole person.” The client and community also benefit through a reduction in the cost of care (Ewing and Tobler, 2014). These factors also contribute to lower recurrence rates. When mental health services are siloed, people do not receive the care they need, but when services connect and support the full person, there is greater success and less burden on APS.
Policy Issues: Dual Diagnoses, Addiction, and Siloed Services
It’s clear that clients experiencing dual diagnoses are a challenge for APS programs. But there have been few provisions for APS clients with dual diagnoses in policy. Broadly, policies for mental health services significantly lag behind our current understanding of best practices. With the CDC estimating that one out of five seniors have some form of mental health challenge and older men having the highest suicide rate, providing specific support for populations with mental health issues is a significant need.
Federal policies offer fewer supports compared with state-specific counterparts. For example, the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requires that commercial health plans provide mental health and substance use disorder benefits comparably to medical and surgical services. In essence, commercial health plans cannot place significantly greater barriers to mental health and substance use disorder treatment than other comparable benefits. In comparison, the California Mental Health Parity Act goes further and requires that all state-regulated commercial plans and insurers provide full coverage for treating all substance use disorders and mental health conditions, including inpatient and outpatient treatments. There is no limitation on benefits or coverage to short-term or acute treatment or medically necessary services and arranged coverage for out-of-network services for medically necessary treatment is required.
Key national programs supporting mental health services include Medicare, Medicaid, Social Security Disability Insurance (SSDI), and Veterans Affairs. In Medicare, mental health conditions are primarily covered through Medicare Part B unless the service requires the client to be admitted as an in-patient. Medicare Part B coverage includes one depression screening per year, individual and group psychotherapy with doctors or other licensed professionals, family counseling, psychiatric evaluation, and medication management. Medicaid benefits vary between states. Some states, such as California, provide full coverage in their Medicaid program (Medi-Cal), while others, such as Georgia, partner with community providers and provide some reimbursement for services performed at certain Care Management Organizations. SSDI uses certain criteria to determine eligibility and provides a limited income for people with mental health challenges who qualify. Lastly, Veterans Affairs provides services primarily related to post-traumatic stress disorder, psychological effects of military sexual trauma, depression, bereavement, and anxiety. This connection may also be a source of general support for clients who are veterans.
Clients facing mental health diagnoses and addiction issues experience many challenges. APS workers engaged with these clients may face greater difficulties and risk of recurrence than with other cases, but research and resources are gradually increasing. By becoming knowledgeable and pursuing resources, APS workers can break down silos and support healing.
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