Adult Protective Services Study on the Impact of COVID-19

Abstract The purpose of study was to explore changes in implemented of APS programs in response to the COVID-19 pandemic. This three-phase study began with telephone interviews with eight state-level APS administrators of early phase “hot-spots” that were used to inform questions for the Phase II national survey of state APS programs. Forty-seven states completed an on-line survey on the effects of the pandemic on work and workload, policy and practice, staff, partnerships, and preparedness. Phase III interviews with 7 local APS programs provided an “on-the-ground” view of challenges of meeting clients’ needs. Although most APS programs reported fewer reports of adult maltreatment than before the pandemic, the stress and disruption of COVID-19 required new work arrangements, to which programs adapted technological and managerial support to care for the needs of both APS staff and the clients they served. Finding provide insight for policy and planning requirements for future catastrophic events.


Methodology
The study design followed a three-step (Phases 1-3) process for identifying any changes in APS practice and policy due to COVID-19, challenges, successes, and specific issues of concern. Phase I involved telephone interviews with eight state-level APS administrators from states considered to be "hot-spot states" at the time of the interviews. The findings from the interviews were then used to inform questions for the Phase II national survey of state APS and Phase III individual and small group interviews with local APS.

Analysis
For the Phase II national survey, survey responses were imported into Excel. Frequencies and percentages were computed to summarize all categorical survey items. Responses from stateadministered and county administered programs were compared to account for variations in administration of APS across states. In addition, categorical and discrete survey items were examined by computing summary statistics within each subgroup and conducting equality of proportions test to estimate the differences across the subgroups. For the Phase III Interviews, there were three stages of analysis -initial observations discussed among research team following each interview, audio transcriptions, and review of the transcribed sessions in light of the Phase II survey findings, with particular attention given to commonalities of responses.

Study of the Impact of COVID-19 on APS
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Effect on Work and Workload
• More than half (66%) of respondents had fewer reports of adult maltreatment and 15% had many fewer reports (total 81%) while 9% had more reports. Eleven percent (11%) experienced no change in the number of reports.
• Slightly over half (52%) of respondents indicated that the level of client need had increased, while 42% saw no change in client need.
• Nearly half of respondents (48%) indicated that, on average, there was no change in client willingness to engage with APS as a result of COVID-19, while nearly the same percent (46%) indicated that clients were less willing to engage with APS.
• The vast majority (80%) of respondents indicated that there was no change in the level of client involvement in planning and decision-making concerning the help and services they needed or received as a result of COVID-19.
• Half of APS respondents (50%) indicated that there was less investigation of cases and for 7% much less investigation as a result of COVID-19, while nearly a third (30%) experienced no change.
• Half of APS respondents (52%) indicated that they were limited to providing fewer services to clients, while 24% had no change, and 20% were providing even more services as a result of COVID-19.

Number and Types of Maltreatment Reports
• Most respondents indicated that there was no change in the types of adult maltreatment their clients were experiencing [physical abuse (39%), sexual abuse (46%), and neglect (37%)].
• Nearly a third of APS supervisors were seeing a small increase in cases of self-neglect (30%) and 23% saw a large increase in cases of self-neglect. Alternately, 16% saw a small decrease and 2% saw a large decrease in self-neglect cases.
• Thirty-one (31%) percent of APS supervisors reported either a small increase (23%) or a large increase (9%) in financial exploitation cases.

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Effect on Staff Work Habits
• The vast majority (73%) of APS staff were able to continue to receive adequate support from management; alternately, 9% of APS supervisors reported that staff support from management decreased as a result of COVID-19.
• Well over half (64%) of APS staff had the technology support they needed, while 18% did not have adequate technology support.
• Nearly half (43%) of APS staff had the training support that they needed, while 16% did not have adequate training support.
• APS supervisor respondents were equally divided (23%) in their responses concerning worker morale.
• Eleven percent (11%) of respondents indicated that worker efficiency had decreased.

Supports Provided to APS Staff
• The overwhelming majority (94%) of APS staff were provided access to personal protective equipment.
• Most (77%) of APS staff had increased communications/check-ins with their supervisors.
• Over half (62%) of APS staff increased opportunities for peer discussion and peer support.
• Approximately half (51%) of APS staff were provided access to mental health resources.

Worker Safety
• Eighty-nine percent (89%) of states reported that staff were concerned with being infected during face-to-face investigations.
• Eighty (80%) of states reported that staff were concerned with infecting clients.
• Over half (59%) of states reported that staff were concerned with not having enough PPE.
• Over half (59%) of states reported that staff were concerned with infecting other staff members.

Policy and Practice Policy Changes for In-Person Visits
• Eighty-nine percent (89%) of states made at least one change in their policies regarding face-toface visits with face-to-face visits with clients and other parties in the allegation.
• Sixty-two percent (62%) of states reported that decisions about face-to-face visits were made in consultation with their supervisor.
• Thirty-eight percent (38%) of states continued face-to-face visits for certain types of maltreatment • Fifty-seven percent (57%) of states continued face-to-face visits for cases in which significant risk has been identified.
• Thirteen percent (13%) of the states no longer made face-to-face visits.
• Thirteen percent (13%) of states made other changes in policies including making face-to-face visits for the initial visit of the investigation only and using virtual methods of contacts such as Face Time and Zoom.

Adjustments to Timeline Requirements
• Eighty-seven percent (87%) of states made no policy changes to timeline for case initiation.
• Ninety-four percent (94%) of states made no policy changes to timeline for completion of investigations.
• Nine percent (9%) of states increased the allowable time for case initiation and four percent (4%) of states increased the allowable time for completion of investigations.
• Four percent (4%) of states removed the time requirement for case initiation and two percent (2%) removed the time requirement completions of investigations.

Interaction with Critical Partners
• More than half of states reported no change in their interactions with mental health services (60%), food banks (57%), and other services (75%) because of COVID-19.
• At least one-third of the states reported increases in interactions because of COVID-19 with health care (43%), law enforcement (41%), and food banks (39%).
• Less than one-fourth of the states reported less interactions with critical APS partners and referral services because of COVID-19 (law enforcement, 21%; health care, 13%; mental health services, 13%, food bank referrals, 4%, and other types of referrals, 9%).

Current Needs for Staff
• Sixty percent (60%) reported that the greatest need of their staff was for child care.
• At least one-fourth of states indicated that their staff needed emergency funds for financial problems (40%), care for adult dependents (37%), and mental health services (29%).
• Twenty-six percent (26%) of states reported that staff needed emergency shelter and 14% indicated that their staff needed food banks.

Current Needs for Clients
• Fifty-eight percent (58%) of states reported that their clients needed technology support and internet capability, respectively, respectively.
• Approximately one-half of the states indicated that their clients needed emergency funds for financial problems (58%) and emergency shelter (53%).
• At least two-fifths of states reported that clients needed mental health services (40%) and care for adult dependents (37%).

Differences between State-Run and County-Run Programs
• State-run programs (74%) made significantly more face-to-face visits, with approval by a supervisor, than did country-run programs (36%).
• State-run programs (9%) had significantly fewer STAFF needs for technical support than did county-run programs (45%).
• State-run programs (44%) had significantly more CLIENT needs for adult dependent care than did county-run programs (9%).

Conclusions
APS programs provide a unique resource to communities around the U.S. COVID-19 has reinforced the unique nature of APS' role and clearly affected the way that APS conducts its business. Especially at the beginning of the pandemic, APS programs found themselves on the "frontline" for addressing the needs of vulnerable adults in their communities. COVID-19 created clear struggles for programs: Study of the Impact of COVID-19 on APS viii • As non-first responders -where and how to get PPE.
• How to observe and assess the well-being of clients without being able to conduct face-to-face visits.
• How to respond to an emergency even though many agency emergency plans did not anticipate or address a pandemic.
• How to support other programs within the community who need front-line resources.
• How to work remotely without having equipment or management processes in place to support it.
The COVID-19 emergency has revealed the distinctive role that APS programs play in their communities and the importance of APS staff to ensuring the health and safety of vulnerable adults. The stress and disruption caused by COVID-19 will result in new work arrangements, to which programs will have to adapt technological support and managerial support to care for the needs of both clients and staff. It will provide insights into the efficacy of policy requirements such as face-to-face visits and perhaps, in the long run, suggest alternatives to accomplishing this vital task. It will help communities -and the role of APS programs within them -better plan for how to deal with pandemics and similar events. The initiative of APS staff may result in greater independence in casework, and thus, greater efficiency and effectiveness over time.
These important and hard lessons learned will only be possible, however, if there are enough resources to meet the needs of staff (e.g., child care, dependent adult care, PPE, financial resources due to family and employment upheavals, mental health services) as well as the clients they serve (technology assistance, internet access, financial resources due to family and employment upheavals, and emergency shelter).

Background
As of September 2020, the number of people infected with COVID-19 in the United States has exceeded 6.5 million and the number of deaths has reached 194,018 (John Hopkins, 2020). While the pandemic has affected many communities, the elder population has a significantly higher risk of infection and fatality. According to the Centers for Disease Control (CDC), the highest hospitalization rates were among people who were 65 years of age or older (436.6 per 100,000). Multiple studies from China, Italy, Washington state, and New York state reveal that being older than 65, especially when paired with chronic or debilitating health conditions, significantly increases the risk of severity of the disease and death (Farrell, et al., 2020;Feinstein, et al.;Giwa & Desai, 2020;Trabucchi & De Leo, 2020). Compared to those aged 18-29, COVID-19 patients aged 65-75 are 90 times more likely to die, those aged 75-84 are 220 times more likely to die, and those over 85 years old are 630 times more likely to die (CDC, 2020).
The social distancing and stay-at-home orders enacted to protect the public against infection are most important for the elderly to follow. However, these same policies are also putting them at higher risk for maltreatment. (D'cruz & Banerjee, 2020;Elman, et al., 2020;Han & Mosqueda, 2020;Makaroun, et al., 2020). The increased social isolation and reduced access to needed care and services are putting elders in even more vulnerable circumstances. Family members and formal and informal caregivers may also be at more risk to abuse due to COVID-19 consequences such as loss of work, financial stress, and conflicting home and work responsibilities. Furthermore, the closing of adult daycare programs, senior centers, and places of worship and reduced contact with service providers, including doctors, nurses, mental health professionals, and social workers also makes preventing and discovering of maltreatment difficult.
Sponsored by the Administration for Community Living, this study investigated the impact of COVID-19 on adult protective services (APS) programs across the country. APS is a social services program provided by state and local governments serving older adults and adults with disabilities who need assistance because of abuse, neglect, self-neglect, or financial exploitation (adult maltreatment). In all states, APS is charged with receiving and responding to reports of adult maltreatment and working closely with clients and a wide variety of allied professionals to maximize client safety and independence (ALC, 2020). Due to the COVID-19 pandemic, APS programs have had to make adjustments in their program implementation due to most state mandates aimed to slow the spread of the virus and save lives. In Phase I of this study where we spoke with APS state administers, we found that by the middle of March 2020, most APS staff were transitioning to remote work and making procedural changes in conducting visits to their clients. In addition, case intake and investigation procedures were modified and questions related to COVID-19 were added. Personal protection equipment (PPE) also became an essential supply in conducting APS work.

Purpose
The purpose of this study was to explore changes were being implemented to APS programs across the country, how cases and workload were being affected, and how APS staff and their work were affected by these changes. In consultation with ACL, the study team developed the following study objectives: • Effect on Work and Workload: Determine the short-term impact of COVID-19 on program work and workload as measured by the impact on the number and types of cases and workload.
• Policy and Practice: Identify, categorize, and analyze the impact of policy and practice changes implemented as a result of COVID-19 and document what changes were considered successful and not successful. Specifically, identify the issues that are arising from the policy and practice changes and document how APS staff have addressed them.
• Effect on Staff: Identify the impact on staff in areas such as job satisfaction, job readiness, and safety and determine how to reduce the negative impacts during future emergencies.
• Partnerships: Identify the impact of COVID-19 on relationships between APS and its community partners (e.g., law enforcement, healthcare, mental health) and determine how those relationship can be improved in an ongoing basis and in preparation for the next emergency. In addition, identify any new or pronounced partnerships, such as social services, and how these relationships can be better prepared or established during times of emergency.
• Preparedness Plans: Identify the impact of COVID-19 on the emergency preparedness plans of APS programs and determine how those plans can be improved, particularly in preparation for the next emergency.

Methodology
The study design follows a three-step (Phases 1-3) process for identifying any changes in practice and policy due to COVID-19 challenges, successes, and specific issues of concern. Phase I involved telephone interviews with eight state-level APS administrators from states considered to be "hot-spot states" at the time of the interviews. These interviews were conducted in early June 2020 and a separate report summarizing the findings is available (Teaster, et al, 2020). The findings from the interviews were used to inform questions for the Phase II national survey of state APS and Phase III individual and small group interviews with local APS.
Phase II involved the administration of a national survey. In addition to Phase I interviewees providing the general themes to be investigated, they also reviewed a draft of the survey and offered additional feedback. The study team administered the survey to all 50 states, District of Columbia, and five territories during a one-month period. Email invitations were sent to APS administrators with instructions to provide state-level responses and were encouraged to discuss responses with any other staff to obtain the most accurate response. Weekly follow-up emails were sent to states that had not responded. At the end of the fourth week, a total of 47 surveys (84% response rate) were completed.
See Table 1 for the breakdown of responses by region.

Table 1. Regional Representation in Phase II Survey (N=56) US Region Number of Responses (Total Possible in Region)
West

(56)
Respondents to the Phase II survey were also asked to provide contact information of local field staff that the study team could invite to participate in Phase III interviews. The purpose of Phase III interviews Study of the Impact of COVID-19 on APS 4 was to gather direct and in-depth information from local field staff in select states. The study team initially planned to invite states reflecting geographic diversity and difference in administration (state versus county).
Phase III was implemented in August 2020. At this time of the COVID-19 pandemic, all states had experienced or were experiencing closures and restrictions; thus, "hot-spot states" was no longer a significant category. Due to field staff constraints, we were limited to states able to provide available staff for interviews. In two states, we only interviewed one staff person. Also due to study timeline constraints, we also were only able to interview seven states out of the nine anticipated. Table 2 below shows the representation of the states interviewed. The study design was reviewed by both WRMA, Inc. and Virginia Tech Institutional Review Boards and deemed exempt from federal regulations protecting human subjects due to the nature of the data collected.

Data Collection Instruments
The study team developed core questions (See Table 3 below) and adapted them from the Phase I findings to develop the Phase II survey questions and Phase III interview guide. While the survey aimed to gather information about the general impact of COVID-19 at the state level, the interviews allowed for an "on-the-ground" view of challenges, concerns, and what worked well to continue to address the needs of APS clients.
The survey was pilot tested by three states to assess the response burden and the clarity and relevance of questions and response options. The final survey was administered via the online survey software, Qualtrics. An emergency OMB clearance was received on July 21, 2020 (OMB Control No. 0985-0067) in order to administer the survey nationally.
Phase III interviews were conducted via teleconference and video conference when available. Trained interviewers used the interview guide to structure and direct the conversation. All participants were asked the same questions and in the same order. However, interviewers also included follow-up questions to extract more details. Interviews were recorded and later transcribed.

Phase II National Survey
The survey responses were imported into Excel for analysis. Frequencies and percentages were computed to summarize all categorical survey items.
To account for variations in the administration of APS across states, responses from state-administered and county administered programs were compared. Categorical and discrete survey items were examined by computing summary statistics within each subgroup and conducting equality of proportions test to estimate the differences across the subgroups.

Phase III Interviews
Phase III data analysis occurred in three stages. The first stage took place during the interviews when the co-facilitators decided which responses to probe further (e.g., case examples) and which to redirect (e.g., general commentary). Next, after each session, the facilitators shared their observations of the information gleaned and how the experiences participants shared compared with previous interviews.
At the completion of each interview, the audio-recorded session was transcribed verbatim. Finally, the transcribed sessions were reviewed in light of the Phase II survey findings, with particular attention given to commonalities among the states' challenges and the ways in which they carried on with their work. Participant quotes illustrate the APS experience in response to the pandemic.

Study Findings
Survey respondents answered questions concerning the effects of COVID-19 on APS work and workload, policy and practice, partnerships, and preparedness and needs. Below are responses to the online survey.

Effects on Work and Workload
In answering the Phase II online survey, APS supervisors were asked a series of questions on how COVID-19 had affected their work, both at the time that many states were asked to lockdown or significantly curtail their activities as well as what they anticipated going forward. Tables 4a-f show their answers about the direct work and workload effects of the virus.    The vast majority (80%) of APS supervisors indicated that there was no change in the level of client involvement in planning and decision-making concerning the help and serviced they needed or received as a result of COVID-19.  Half of APS respondents (52%) indicated that they were able to provide fewer services to clients, while 24% had no change, and 20% were providing even more services as a result of COVID-19.

Number and Types of Maltreatment Reports
Respondents were asked about any changes their offices had experienced in the types of maltreatment they were seeing as a result of COVID-19. With the exception of self-neglect, approximately a fourth of respondents did not know the answer to this question. • Nearly a third of APS supervisors were seeing a small increase in cases of self-neglect (30%) and 23% saw a large increase in cases of self-neglect. Alternately, 16% saw a small decrease and 2% saw a large decrease in self-neglect cases.
• Thirty-one (31%) percent of APS supervisors reported either a small increase (23%) or a large increase (9%) in financial exploitation cases.

Effect on Staff Work Habits
The vast majority of states (96%) implemented remote work as a result of shelter-in-place requirements.
For those states whose employees worked from home as a result of shelter-in-place requirements, 36% did so all the time, 56% most of the time, and 9% did so some of the time. Figure 1 presents how remote work affected staff members.

Figure 1. Overall impact of remote work (multiple responses)
• The vast majority (73%) of APS staff were able to continue to receive adequate support from management; alternately, 9% of APS supervisors reported that staff support from management decreased as a result of COVID-19.
• Well over half (64%) of APS staff had the technology support they needed, while 18% did not have adequate technology support.
• Nearly half (43%) of APS staff had the training support that they needed, while 16% did not have adequate training support.
• APS supervisor respondents were equally divided (23%) in their responses concerning worker morale.
• Eleven percent (11%) of respondents indicated that worker efficiency had decreased.

Additional Roles and Responsibilities
A number of states reported taking on additional roles and responsibilities as a result of COVID-19.
These included providing additional services to clients (e.g., health screenings) (41%), assisting other organizations (e.g., food banks, shelters) (69%), and other (e.g., assisting with cases of repatriation,  Figure 2 shows additional supports provided to workers as a result of the virus. Nearly all were provided access to PPE, but other supports (11%) included an increase in the number of management meetings, an increased focus on self-care of the staff (e.g., webinars and meditation), employee assistance such as counseling, and the purchase of video conferencing devices to reduce vectors of virus transmission.

Figure 2. Supports provided to APS workers as a result of COVID-19 (multiple responses)
• The overwhelming majority (94%) of APS staff were provided access to personal protective equipment.
• Most (77%) of APS staff had increased communications/check-ins with their supervisors.
• Over half (62%) of APS staff increased opportunities for peer discussion and peer support.
• Approximately half (51%) of APS staff were provided access to mental health resources.

Worker Safety
Respondents were asked to document the safety concerns that staff raised. Not surprisingly, becoming infected or infecting others was a primary concern (Figure 3). Though a small percentage of the concerns, other safety concerns raised included not having adequate technology to conduct work, inadequate staffing to ensure that staff and clients were protected, and reduced locations for bathroom breaks that did not require APS staff to make purchases.

Figure 3. Safety Concerns that Staff Raised (multiple responses)
• Eighty-nine percent (89%) of states reported that staff were concerned with being infected during face-to-face investigations.
• Eighty (80%) of states reported that staff were concerned with infecting clients.
• Over half (59%) of states reported that staff were concerned with not having enough PPE.
• Over half (59%) of states reported that staff were concerned with infecting other staff members. Being infected during face-to-face investigations I was really amazed with our staff. At first, when all this began, it was very scary to a lot of us. They were frightened to go out. They had not only themselves, but their families to think about. But I don't know of anyone, statewide, that refused to go. They all knew that this is what they had taken on as what they do, and they went.

Key Findings from Surveys and Interviews Effect on Work and Workload
Most state APS programs did not see changes in the types of abuse reports that they were investigating.
However, about a third of states (32%) reported an increase in self-neglect cases. Thirty-two percent (32%) of states saw an increase of financial exploitation cases, while 25% saw a decrease.
Over half of state respondents (57%) indicated that they were investigating much less or less than pre-COVID-19 and that about half (54%) were providing many fewer or fewer services to clients.
Nearly half of states indicated that their clients were less willing to engage with APS staff, although a commensurate number of states reported that there was no change.
Fortunately, most APS staff were able to continue to receive adequate support from management and technological support, though staff in a fifth of states experienced insufficient support related to technology. Worker morale declined in more than a fifth of states and in a small percentage of states (11%) staff efficiency decreased.
Most APS staff were provided with adequate PPE as well as increased opportunities for communication and peer discussion, support, and access to mental health services. Safety concerns of staff were overwhelmingly related to contracting infections during face-to-face investigations, infecting clients, and not having enough PPE, being infected by other staff, and infecting them.

Policy and Practice
Responses to a series of questions about policies and practices either in place or put into place to address operations considering COVID-19 suggested several changes occurred because of the pandemic. Of note, only one-third of the states (34%) were tracking COVID-19 related cases in their case management system.
Policy changes focused on in-person visits ( Figure 4) and adjustments to timelines for case initiation and resolution (Table 6).
Face-to-face with my workers, I do a lot of Zoom, Skype and team meetings, the Brady Bunch look. With clients, some of our elderly clients, cognitive decline clients, you really can't do these types of meetings.

Figure 4. Policy changes for in-person visits with clients and other parties involved in the allegation because of COVID-19 (multiple responses)
• Eighty-nine percent (89%) of states made at least one change in their policies regarding face-toface visits with face-to-face visits with clients and other parties in the allegation.
• Sixty-two percent (62%) of states reported that decisions about face-to-face visits were made in consultation with their supervisor.
• Fifty-seven percent (57%) of states continued face-to-face visits for cases in which significant risk has been identified.
• Thirty-eight percent (38%) of states continued face-to-face visits for certain types of maltreatment.
• Thirteen percent (13%) of the states no longer made face-to-face visits.
• Thirteen percent (13%) of states made other changes in policies including making face-to-face visits for the initial visit of the investigation only and using virtual methods of contacts such as  • Eighty-seven percent (87%) of states made no policy changes to timeline for case initiation.
• Ninety-four percent (94%) of states made no policy changes to timeline for completion of investigations.
• Nine percent (9%) of states increased the allowable time for case initiation and 4% of states increased the allowable time for completion of investigations.
• Four percent (4%) of states removed the time requirement for case initiation and 2% removed the time requirement completions of investigations.

Key Findings from Surveys and Interviews for Policy and Practice
With the onset of COVID-19, most states made changes in their investigation policies. In two-thirds of the states, workers made decisions about the need for face-to-face client visits, the standard approach for assessing new cases and monitoring on-going cases, in consultation with their supervisor.
The characteristics of the case, including the type of maltreatment in more than one-half of the states and high-risk cases in more than one-third of the states underpinned decisions to continue with face-toface visits. A theme from interviews with five local APS programs was that many face-to-face visits were held telephonically.
And so definitely we changed the way we practice. We tried to limit the amount of face to face contact that we had with individuals. I will tell you that a lot of the stuff that we were able to do, if we were able to handle it telephonically, we did so as well.
While most states did not adjust their timelines for case initiation and completion, those that did either increased allowable time or removed the time requirement entirely.

Partnerships
Throughout the lifecycle of a case, APS often partners with a variety of state and community service organizations and referral services to investigate allegations of mistreatment and support older persons who experience mistreatment. APS supervisors identified changes in the frequency of interactions with their partners because of COVID-19 (Table 7).
• At least one-third of the states reported increases in interactions because of COVID-19 with health care (43%), law enforcement (41%), and food banks (39%).
We only required a face-to-face visit and allowed a lot of flexibility on what could be considered face-to-face. It could be a telephone call. If the client had the ability to do something like Zoom, or FaceTime, or something, we would count that as a face-to-face visit.
• Less than one-fourth of the states reported less interactions with critical APS partners and referral services because of COVID-19 (law enforcement, 21%; health care, 13%; mental health services, 13%; food bank referrals, 4%; and other types of referrals, 9%).

Key Findings from Surveys and Interviews for Partnerships
While conducting most of their work remotely, two-thirds of the APS programs maintained or increased their pre-COVID interactions levels with their key community partners and referral services. More than one-third of the states reported that frequency of interaction with law enforcement, health care providers, and food banks referrals has increased.
Although 60% of states reported no change in their frequency of interactions with mental health services, 27% increased their interactions with mental health services.
Few states reported less frequent interactions with their partners and sources of referral. This decline was often a result of the demands being placed on the partner agencies. In some states, APS established new partnerships to assist with their case investigations and management.
We relied a lot on our in-home nursing agencies or our agencies that provided home health care, cleaning, and things like that to really give us more vivid descriptions of what's going on. A lot of times by using their cellphones to help us do that. We set up a lot more people with telemedicine.
We have basically been working with the same agencies and…, they're relying more heavily on us.

Preparedness and Needs
Sixty-three percent (63%) of states reported having APS emergency preparedness plans in place before COVID-19. Even so, only 25% of APS supervisors noted no unmet and undermet staff needs. Eleven percent (11%) of states reported that their clients had unmet or undermet needs. Figure 5 captures needs for staff. Though a small percentage, needs not captured below include the ability for staff to scan and print documents, photography equipment, adequate numbers of staff, and laptops for all case managers and supervisors.

Figure 5. Current needs for staff that states do not have at all or do not have enough (multiple responses)
• Sixty percent (60%) reported that the greatest need of their staff was for child care.
• At least one-fourth of states indicated that their staff needed emergency funds for financial problems (40%), care for adult dependents (37%), and mental health services (29%).
• Twenty-six percent (26%) of states reported that staff needed emergency shelter and 14% indicated that their staff needed food banks.

Figure 6. Current needs for clients that states do not have at all or do not have enough (multiple responses)
• Fifty-eight percent (58%) of states reported that their clients needed technology support and internet capability, respectively.
• Approximately one-half of the states indicated that their clients needed emergency funds for financial problems (58%) and emergency shelter (53%).
• About two-fifths of states reported that clients needed mental health services (40%) and care for adult dependents (37%).

Key Findings from Surveys and Interviews for Preparedness and Needs
Although emergency preparedness plans were in place for almost two-thirds of the APS programs, Most of what our preparedness was for hurricanes, tropical storms, natural disasters, but as a program, we didn't have a plan. Now, at the state level, I know there's a state-level pandemic plan that was in place.
to move quickly to develop guidelines and procedures for carrying out their primary roles and responsibilities.
After making initial adjustments needed to work remotely and obtaining the PPE necessary to conduct their jobs, APS staff in 75% of the states continue to have one or more unmet or undermet need. Such needs include both professional needs (e.g., PPE, internet capability, technology support) and personal needs (e.g., child and dependent adult care, financial support, mental health services).
States reported that more than one-half of their clients continued to have needs with respect to technology support and internet capabilities needs. Clients needed emergency funds to help resolve financial problems, emergency shelter, mental health services, and care for dependent adults. Having no or insufficient support, likely increased their risk of maltreatment.

State and County-Administered Programs
We compared state-administered and county-administered programs to determine if there were differences in the implementation of policies for in-person visits with clients and other parties involved in an allegation and for staff and client needs. As shown in Figure 7, there were significant differences between the state and county administered programs concerning making face-to-face visits based upon consultation with a supervisor (74.0 versus 36.0, z = 2.29. p = .0219). State-run programs (74%) made significantly more face-to-face visits, with approval by a supervisor, than did country-run programs (36%).
Part of our assessment process is that we don't want re-abuse. Whether or not we go back out and there really isn't abuse, there are just concerns, part of the ability for my workers before they can turn it into me is, what have they done to mitigate so that it's not going to come back?

Figure 7. State-Run and County Run Programs (Policy Changes)
Significant differences also were found between the state and county administered programs concerning staff needs for technical support (Figure 7; 9.0 versus 45.0, z = -2.271. p = .0067). State-run programs had significantly fewer staff needs for technical support than did county-run programs (9% vs 45%, respectively).

Figure 8. Comparison between state-run and county-run programs (unmet staff needs)
As shown in Figure 9, there were significant differences between the state and county administered programs concerning client needs for adult dependent care (44.0 versus 9.0, z = 2.109. p = .0349). Staterun programs (44%) had significantly more client needs for adult dependent care than did county-run programs (9%). 0% 10% 20% 30% 40% 50% 60%

State-run vs. County-run Programs on Staff Needs
State-run County-run

Figure 9. State-Run and County Run Programs (Unmet Client Needs)
• Seventy-four percent (74%) of state-run programs made significantly more face-to-face visits, with approval of a supervisor, than did country-run programs (36%).
• Nine percent (9%) of state-run programs had significantly fewer STAFF needs for technical support than did county-run programs (45%).
• Forty-four percent (44%) of State-run programs had significantly more CLIENT needs for adult dependent care than did county-run programs (9%).

Study Limitations
The national survey was designed assuming that all APS programs follow state mandates, policies, and procedures. However, several county-administered states expressed frustration that their general answers to the survey were not reflective of some counties in their state. County-administered APS programs have their own discretion on implementation, including COVID-related modifications. In instances where the state provided recommended COVID-19 modifications, there were no mechanisms for determining the extent to which counties implemented them. The study team instructed these states to consult other staff and respond to the survey with the best representative answer. The survey received 11 responses from the 15 county-administered states. Due to the constraints of the study timeline and limitations of field staff, the study team was also not able to interview as many staff or states as originally planned. Although information from the interviews helped to illuminate the challenges and concerns APS programs faced, small numbers limited the diversity and complexity of stories from which to draw generalizable conclusions.
Finally, the study was conducted during a window of time that was very fluid. The impact of COVID-19 changed as states assessed and reassessed the severity of the local pandemic and their response. In addition, issues that we heard in the Phase I interviews such as the lack of PPE or technology were often resolved by the time we conducted the survey, showing APS leadership's ability to take issues as an emergency and respond quickly.

Discussion and Conclusions
APS programs provide a unique resource to communities around the U.S. COVID-19 has reinforced the unique nature of APS' role and clearly affected the way that APS conducts its business. Especially at the beginning of the pandemic, APS programs found themselves in a catch-22 situation -they were not technically "first responders" yet they were the "frontline" for addressing the needs of vulnerable adults in their communities. The pandemic created clear struggles for programs. These included the following: • As non-first responders, where and how to get PPE.
• How to observe and assess the well-being of clients without being able to conduct face-to-face visits.
• How to respond to an emergency even though many agency emergency plans did not anticipate or address a pandemic.
• How to support other programs within the community who need front-line resources.
• How to work remotely without having equipment or management processes in place to support it.
At the beginning of the pandemic, many programs scrambled to address these needs as states instituted working from home due to shelter-in-place orders and programs implemented safety precautions to protect workers and clients. Less affected were those programs that had already made provisions for working at home, as they had fewer technological problems to resolve and less training to conduct to implement remote work.

Changes in the Workplace
It is likely that many to most programs will continue with some type of remote work because the pandemic has created budgetary stress for programs and remote work creates the opportunity for increased program efficiency (e.g., greater staff flexibility, smaller office footprints, new avenues of team communication). As working from home becomes normalized, remote work will succeed only if programs are able to provide staff the technological tools they need and are able to create new workplace environments and managerial processes to support remote work.
Our study found that programs are aware and responsive to these challenges. For example, while accessing PPE was a problem cited by many programs in the beginning of the pandemic, by the time of our study, nearly all APS staff were provided access to PPE as the pandemic continued -supervisors even delivered it to the home of staff in several instances. It is also notable that the vast majority of APS staff increased communications/check-ins with their supervisors. Importantly, APS supervisors gave serious attention to the care of their staff, including making themselves as accessible as possible, including peer discussion time and opportunities for self-care, increasing access to mental health services, and providing flexibility with scheduling.
Although remote work creates opportunities for program efficiency, it also creates real-life stress for staff. We found that staff had needs related to child care, access to emergency funds due to financial

Changes in Policy and Practice
The most significant changes to APS policy and practice were related to face-to-face visits. One of APS' critical roles in the community social service system is that it visits clients in their home instead of the clients coming to them. For non-critical cases, COVID-19 took away this distinctive role for most APS programs, at least for a while. Over half of states continued face-to-face visits for certain types of maltreatment, while a small percentage discontinued face-to-face visits entirely for a brief time.
While staff were able to use technology for face-to-face visits, it was often an inadequate solution when the clients did not have access to it or know how to use it. Also, it did not allow the insight gained from being on-site to actually see an individual and view the environment in which he or she lives.
Even though not technically first responders, another unique aspect of APS programs is the time-sensitive nature of assessing emergency and safety needs of clients and that APS is often the first entity to come into contact with a client. This time sensitivity is reflected in case initiation policy timeframes and investigation timeframes. Our study found that several states have lengthened or waived the time requirements for investigation requirements -including case initiation and completion -in recognition of the special circumstances impacting the ability to conduct investigations.

Interface with Critical Partners
Partners are critical to the success of APS. While this is true of most social service program, APS is particularly dependent on relationships with both law enforcement and community-based organizations. The unique needs created by COVID-19 made these partnerships even more critical. Our study found that at least a third of states increased their interaction with law enforcement, health care,

Emergency Preparedness
In times of emergency, APS staff have critical roles to play in their communities because of their connection to at-risk individuals and relationships with communitybased organizations. APS programs, however, were not prepared for the unique nature of COVID-19.
While most states had some form of preparedness plans, they were focused primarily on natural disasters that were likely to occur in the geographic areas that they served. For example, in the southeast, APS emergency plans were geared toward hurricanes or tropical storms. In the northeast, APS emergency plans typically addressed the effects of rainstorms or snowstorms. In the Pacific Northwest, emergency plans addressed wildfires. These plans operated on the prevailing wisdom of plans for moving older and vulnerable adults to a safer place rather than mass sheltering in place and for a protracted rather than brief period of time. While most emergency preparedness plans did not address the needs that the COVID-19 pandemic has presented, plans were in place to address an emergency of some kind. APS programs that had, by necessity, already instituted technology for working from home or in the field were in a far better position to use technology in the current pandemic. APS programs that had not done so earlier pivoted from standard office practices, sometimes doing so with mere days of notice. Many programs learned that working from home allowed staff to better manage their time, but there had to be adequate technological support and a conducive home environment for them to do so.
In a number of instances, when critical partners could not go to visit clients, APS stepped in to fill the void and so became the critical lynchpin for clients desperately needing their services. Similarly, some APS programs used law enforcement to make visits for them before PPE became available.

Differences between state-run and county-run programs
Comparisons between state and county-administered programs revealed significant differences between the two models in policy changes, staff needs, and client needs. Although county-administered programs vary in the level of support provided from the state, some counties are likely to have fewer resources available in all of these areas, especially in rural locations. For instance, technical support for county-administered programs was noted as a need much more frequently than state-administered programs. States are likely to have a more robust and well-staffed technical team than many smaller counties with fewer employees. Conversely, county-administered programs may have a closer relationship with local services as they are more "specialized" within a distinct location, as client needs for emergency shelter were endorsed at a much higher rate for state-administered programs. Counties exercised more policy flexibility, with states less likely to relax face to face visit requirements.

Summary and Observations
The interviews of state and local APS staff revealed the ingenuity and dedication of APS staff, at levels that were surprising even to APS administrators.
In general, after appropriate training and support, staff were able to conduct investigations, relying upon collaterals for information in ways that they may have not earlier. They learned to use PPE appropriately, even though its use was familiar to many APS staff. Staff were inventive in the ways that they worked cases with partners, upon whom they relied, and more often, upon whom the partners relied heavily.
The COVID-19 emergency has revealed the distinctive role that APS programs play in their communities and the importance of APS staff to ensuring the health and safety of vulnerable adults. It has made clear that this role extends beyond simple APS investigations. The stress and disruption caused by COVID-19 will result in new work arrangements, to which programs will have to adapt technological support and managerial support to care for the needs of both clients and staff. It will provide insights into the efficacy of policy requirements such as face-to-face visits and perhaps, in the long run, suggest alternatives to accomplishing this vital task. It will help communities -and the role of APS programs within them --better plan for how to deal with pandemics and similar events. The initiative of APS staff may result in greater independence in casework, and thus, greater efficiency and effectiveness over time.
These important and hard lessons learned will only be possible, however, if there are enough resources to meet the needs of staff (e.g., child care, dependent adult care, PPE, financial resources due to family and employment upheavals, mental health services) as well as the clients they serve (technology assistance, internet access, financial resources due to family and employment upheavals, and emergency shelter).
Just one last thing that I wrote down that my staff talked about and it's that they know that they're often the only one that can protect and care for some of our most abused and neglected elders. And without them, my staff, going out there, I mean it's the only thing that stands between them and harm and that's not a minor thing and my staff takes that very seriously and I love my staff for it. I have mad respect for them and how much they care about our endangered adults. So I just wanted to mention that because I thought it was important that they mentioned it to me.

What additional roles and responsibilities have APS workers adopted as a result of COVID-
19? (Select all that apply) Consider any new functions that APS workers has been required to add to their normal job.