Patient Safety

When There's Danger in the Home for Clients

The signs of elder abuse & how home health providers can address it

By Michelle Love

Charlie Hubbard said he’s had plenty of experiences identifying elder abuse in his professional career and referring cases to his state’s authorities. Hubbard is a physical therapist for CenterWell Home Health in Hoover, Alabama, and has worked in the industry for eight years.

“A lot of times what we see on the news are the most egregious examples [of abuse], and a lot of times people are expecting it to be this obvious,” he said. “But a lot of times it's very nuanced, and we're in a very good position to identify that with a keen eye when you go into the home and you interact with those patients and those caregivers.”

There are several types of abuse:

1. Physical Abuse

Hubbard said that when it comes to physical abuse, care providers should look for the more obvious signs, such as bruises, welts, frequent unexplained injuries or accidents that don't necessarily line up with a patient’s history or with what the patient or their family are saying was the cause.

2. Neglect

With neglect there are several different categories home health providers should look out for, including personal and residential hygiene.

“You have things like matted hair, nails overgrown; smelling like urine and feces is a common one,” he said. “Look at the environment itself—do they have the proper necessities? Is the house itself livable? We've had houses that needed to be condemned due to black mold, for example.”

Medical neglect is an area that is often forgotten, including the lack of medical needs being tended to or consistent medication management. Home health providers should monitor to make sure patients are being given their medication in a timely manner or that a family caregiver isn’t withholding it for some reason.

3. Financial Abuse

Financial abuse can take many forms, according to Hubbard. Family members may use patients' income or valuable items to their advantage.

“Is the caregiver withholding medication due to monetary reasons or due to emotional abuse reasons where they're trying to leverage something in their favor?” Hubbard asked. “You’re also going to be seeing missing items—my missing bracelet, my missing watch, or a lot of times the patient's going to say, ‘This person's stealing from me,’ and you're like, ‘Oh, okay, tell me more about that.’”

How to Know It’s Abuse

Hubbard said one of the first steps is determining whether the patient is in immediate danger, and if the answer is yes, that warrants an immediate call to 911. If the answer is no, the first step is to approach the patient and the family caregiver to discuss your suspicions.

“Where you're going to find the most information and dive the deepest into parsing out what's going on in that house is talking to the caregiver, talking to the patient and observing how that caregiver acts around that patient,” he said. “That interaction is going to tell you more than a lot of stuff.”

Observing how a family caregiver responds to feedback can also be a big clue. If they seem genuinely interested and open to advice from a home health provider, that’s a good sign their heart is in the right place. However, if the family member seems flippant or less invested, it could indicate suspicious behavior, Hubbard said.

Home health providers should also take the patient’s mental and physical abilities into account.

“What level and functional capacity—mentally or physically—does that patient have, and where does the caregiver fit into that piece?” Hubbard said. “You're going to find the more vulnerable elder population, not always but generally are more susceptible to abuse. So essentially, if your gut is telling you this doesn't feel right, you report it.”

Approaching the Subject

Once a suspicion of elder abuse comes to light, home health providers are required to address the situation and report the abuse. This begins with directly approaching the subject to the patient and their family caregiver. Hubbard said the “multimillion-dollar question” that home health providers ask themselves is how to do that.

“A lot of times, I am getting the patient and the caregiver together, and we're talking and we're educating,” he said. “A lot of times you're going to find the caregiver is overworked or over stressed, and you've got to educate the patient and the caregiver and bridge those needs together—that’s what I generally find is most effective.

“You are going to see a caregiver forget to give a medication,” he continued. “You're going to see they came home late, and they couldn't get the linens changed before you come. Does that necessarily constitute neglect? It’s kind of that gray area. If there's a pattern, yes; if you're tipping off red flags where this patient is injured, yes, obviously; but sometimes it's a little more nuanced than that.”

The main goal is to make sure patients and their family caregivers are connected to the proper resources, such as state or local agencies that work to ensure the environment is safe for the patient.

“Our sole job is to help them the best way that we can and provide them with the resources so that they can functionally and independently live their best lives,” Hubbard said.

Hubbard has found the best approach is to talk to patients as if they were your own family. Older adults are more open to environmental changes when family caregivers and home health providers work with them at the same level.

“What I see [patients] are afraid of the most is being alone and being forgotten, and that obviously ties into neglect,” he said. “Neglect means you are forgotten, right? And just letting them know, ‘Hey, we're here. You've got someone in your corner. We are here to fight for you.' Once they see that, a lot of that fear improves. But you might be that one lifeline to the outside world, to these resources, and so we've got to be mindful of that and cultivate relationships that are conducive to finding solutions for very complex problems.”

Doing Your Due Diligence

Ultimately, a patient may or may not accept a provider’s help in reporting abuse due to a variety of different factors. Hubbard said a person is less likely to report abuse if the abuser is an immediate family member such as a son or daughter. However, making sure you’re the best source for getting a patient help is part of a home health provider’s responsibility.

“If you're not sure, just report it, and you've done your due diligence,” he said. “But again … that doesn’t necessarily fix the problem, dependent on their reception of the solutions. So, it's kind of tricky and gray, but at the end of the day, I think if you go in with your heart in the right place to help these people, you're going to make the right decisions.”