Impact of a collaboration revolving around virtual capacity evaluations

Abstract Objective To assess the impact of virtual capacity assessments on access to medical care, community supports, and transitions to higher levels of care. Study Setting Virtual capacity evaluations of homebound suspected elder abuse/neglect/financial exploitation victims identified via exclusion criteria and initiated by Cuyahoga County adult protective services (APS) and conducted with Cleveland Clinic Geriatric Medicine. Study Design A retrospective chart review was conducted in conjunction with APS using their database to determine the outcomes of individuals who underwent virtual capacity evaluation from May 2020 through September 2021. Variables collected included completion of a statement of expert evaluation, guardianship assignment, offering community services, transfer to a higher level of care, and establishment of primary care. Data Collection/Extraction Data were extracted from medical records and the APS database. Outcomes were measured as percentages. Principal Findings Fifty‐four individuals underwent evaluation. Statements of expert evaluation were completed in 38 cases (70%). Guardianship was assigned in 28 cases (52%). Community services were offered to 51 (89%). Thirty‐one (57%) remained at home. At baseline, only 23 (43%) were receiving primary care. Post evaluation, 44 (81%) were connected or reconnected to their medical provider. Conclusion Of individuals who underwent our virtual capacity evaluations, most were able to remain at home, offered community services for support, and linked to primary care.

• Little data were published demonstrating the impact that capacity evaluations have on the persons involved What this study adds • Virtual capacity evaluations can be successfully conducted within the framework of an Age-Friendly Health System (including the incorporation of cognitive testing (Mentation), medication review/adherence (Medications), gait assessment (Mobility), and working to keep a person at home as much as possible ("What matters most")) • By collaborating with a community partner, such as adult protective services, the impact of this model on the individuals concerned can be monitored-this includes connection of individuals to appropriate community resources, reestablishment of connection to medical care, and determination of the need for assignment of a guardian • All evaluation recipients were more likely to be connected to primary care and remain at home even if they were deemed to have impaired decision making capacity but accepted home services.

| INTRODUCTION
Capacity assessments of suspected victims of neglect, abuse, and/or exploitation are often requested of physicians by local adult protective services agencies. Access to such services can be very limited, with one survey conducted in California in 2020 showing 53.1% of counties having no access to such assessments. 1 Although capacity evaluations are ideally performed in person, virtual assessments can overcome barriers, such as lack of transportation, impairments in ambulation, and refusal by the individual to go to a scheduled physician visit for the evaluation. Virtual capacity evaluation programs have been implemented in various locations in the United States. Guidance on how to implement such programs has been published. 2 Despite capacity evaluations being performed regularly by clinicians, outcomes of such assessments have been difficult to track, particularly whether or not guardianship was assigned or where persons ended up living after such assessments have been completed. In fact, two surveys conducted looking at guardianship and conservatorship data found that accurate data were lacking at the state levels. 3,4 Age-Friendly Health Care Systems highlight four specific elements that represent the foci of evidence-based quality care for older persons. These include mentation, mobility, medications, and "what matters most" -called the "4Ms." The virtual capacity evaluation conducted with APS fosters the 4Ms principles in multiple ways.

| Mentation
The virtual capacity evaluation predominantly revolves around cognitive function and decision making capacity. Evidence-based cognitive tests are utilized to assess cognitive function, and decision making capacity is assessed utilizing best practices in determining a person's ability to make medical and financial decisions for themselves. 5 This data were key in determining if the assignment of guardianship would be recommended following this evaluation.

| Mobility
As a component of this evaluation, a virtual assessment of gait (when possible) is conducted as part of the physical examination. Additionally, observations from the adult protective services nurse identify problems with ingress and egress from a person's residence, physical barriers to safe mobility around a person's household, and general observations about a person's walking and balance. This is useful information in assessing the person's safety in the home.

| Medications
Additionally, medication reconciliation and pill count are conducted as part of this evaluation in conjunction with the nurse. This also helps provide information regarding a person's comorbidities (especially when access to previous medical records and medical history is limited) and adherence to the medication regimen (based on a pill count from the nurse). Findings from this part of the evaluation inform 1 as above and help identify potential needs for the individual to maintain them at home and also connect them to medical care if a gap is identified in the management of their chronic illnesses.

| Matters most
Maintaining independence and keeping a person in the community through the addition of community resources is a primary goal of this assessment, which is often aligned with the client's wishes and desires, those of the family (in many circumstances), and of the community. Such resources are also helpful in potentially reducing caregiver strain and burden (which can increase the risk of nursing home placement) and may also provide the caregivers with assistance in planning for a move to a higher level of care if needed in the future.
Adult protective services initiate this evaluation once concerns about abuse, exploitation, or neglect are reported, with the goal of identifying the needs of the individual, providing community resources to support them at home if possible, and identifying those that are lacking in medical care. If appropriate, APS also helps those who are unable to remain in the community move to a more supervised setting by fostering realistic discussions about plans of care if that individual was no longer able to stay at home; this helps keep the person involved in the decision making as much as possible, even if cognition is impaired.
Using this as a framework, geriatricians at the Cleveland Clinic implemented a virtual capacity evaluation program in collaboration with Cuyahoga County adult protective services (APS). This was particularly important during the COVID-19 pandemic when inperson visits became extremely limited, and the incidence of elder abuse was rising nationally. 6 The utilization of telehealth visits during the pandemic was shown to be particularly beneficial for older persons. 7 The need for this evaluation is triggered by APS when cognitive concerns or unaddressed medical issues are identified by the APS social worker who conducts an initial in-person assessment.
Arrangement for another evaluation with an APS nurse is made at that time. The virtual capacity evaluation was conducted in this collaboration with the APS nurse (who is present in person with the patient) and the geriatrician (connected via a video platform remotely to interview the patient.) The APS nurse obtains vitals (including weights), conducts a medical review with pill count, and facilitates the cognitive evaluation conducted by the geriatrician.
The presence of the nurse at the patient's home helps overcome potential barriers that an older person may encounter when using newer technologies. 8 Many of the components and goals of this virtual capacity evaluation integrate the elements of the 4Ms (mentation, mobility, medications, and what matters most). 9 The geriatrician is able to conduct a limited virtual physical examination that includes an evaluation of gait and mobility. A cognitive evaluation is always attempted; this includes the Saint Louis University Mental Status Examination (SLUMS) 10  We sought to determine the impact of our collaboration on the individuals evaluated within the context of the 4Ms.

| METHODS
A retrospective chart review was conducted in conjunction with APS using their database to determine the outcomes of individuals who underwent virtual capacity evaluation from May 2020 through September 2021. Fifty-four individuals underwent this evaluation.
Data collected included age, gender, whether or not a statement of expert evaluation was completed, if a guardian or conservator was assigned, if community services to support the individual were recommended, if these services were accepted, if the individual was able to remain in their current residence or were placed in a more supervised setting (e.g., nursing home or another long-term-care facility), if the individual was receiving routine medical care before this evaluation, if they were connected/reconnected to medical care afterward, if they had a diagnosis of dementia before this evaluation being conducted, and the type or types of elder abuse that were alleged. The data collected were binary in nature ("yes" or "no") for the variables being studied. Connected to primary care before evaluation 16 7 Connected to primary care after evaluation 33 11 Dementia diagnosis before evaluation 13 4 Single abuse type alleged 27 13 Neglect (N) 3 0 Self-neglect (SN) 17 10 Financial exploitation (FE) 7 2 Verbal abuse (VA) 0 1 Multiple abuse types alleged 11 3 Neglect + financial exploitation 3 1 Self-neglect + financial exploitation 3 2 Physical abuse + financial exploitation 1 0 Neglect + self-neglect 4 0 Services offered Descriptive statistics were measured to assess the percentage of patients for whom a particular outcome was reached.

| RESULTS
The APS database and the medical records of 54 individuals who underwent a virtual capacity evaluation were reviewed. Table 1 shows the demographic characteristics of this cohort. The average age was 79. Nineteen were men (35%), and 35 were women (65%).
Allegations of elder abuse that initiated APS involvement included abuse due to a single cause in 40 cases (74%) and abuse due to multiple causes in 14 cases (26%   Of the 10 individuals who were not assigned a guardian by the court, six were offered services of which three (50%) accepted and three (50%) refused. Of those who accepted services, two remained at home, one moved in with another family member. Of those who refused services, two stayed at home and one was placed into LTC.
An analysis was conducted to look at the relationship between the outcomes of this assessment process and the previous connectedness of the client to a primary care provider-this data are detailed in

| DISCUSSION
Involvement of APS is often accompanied by assumptions that the concerned individual is likely to be assigned a guardian and placed in a nursing home-this is a common misconception. 15 Resources and community services were offered in a vast majority of the cases in our study (48 of 54 cases)-this is consistent with current practice within the State of Ohio. 16 Regardless of whether a person was assigned a guardian or not, the probability of being placed in LTC was similar for those who refused or accepted community services. For the 16 persons who did not have a SEE completed (and no guardian was assigned), all remained at home whether they accepted services or not. Yet for those who were assigned a guardian (28 persons), a higher percentage of these individuals who accepted community services were able to stay at home compared to those who did not: 5 of 9 (56%) versus 5 of 18 (28%) as noted in Table 2. Community services appear to be helpful in keeping persons living in their own homes by serving as an intervention to help support these persons. They also seem to be key in preventing LTC placement. These interventions and outcomes would seem to contradict this misconception of APS's role in the evaluation and management of the cases they encounter.  Additionally, we showed that persons who are evaluated and determined to lack decision making capacity, have a guardian assigned, and are offered and accept community resources are more likely to remain at home than those who refuse-helping to achieve "what matters most" for this group of individuals.
Ultimately, our data show that geriatric medicine collaboration with adult protective services, even through the use of a virtual platform, positively impacts socially isolated persons who have experienced one or multiple forms of elder mistreatment or neglect by connecting them to essential community services to keep them at home, facilitating arrangement of appropriate surrogate decision makers, reconnecting them to needed medical care, and successfully keeping many of them out of long-term-care facilities-all outcomes that reflect the focus of the 4Ms. Although larger studies will certainly be helpful in showing the impact that this sort of program can have in a community, we hope our work can be used to foster continued dissemination of this innovative approach to care and help other institutions implement a similar program.

ACKNOWLEDGMENTS
The authors wish to acknowledge Kelly Clemings RN, Natasha Pietrocola MSW, and Larry Vavro MSW, whose collaborative spirit and championship for vulnerable older persons at Cuyahoga County adult protective services facilitated the development of this successful collaboration.