A Matter of Demographics?
An Increasing Number of New Yorkers
Are Aided by Adult Protective Services
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In 2010, 1.0 million New York City residents were age 65 or older. The Department of City Planning projects this number will grow to reach 1.36 million, or nearly 16 percent of the population, by 2030. With age often comes physical or cognitive impairments, and because seniors frequently live alone, these conditions can make it hard for them to care for themselves at home. This demographic shift may already be having an effect, reflected in the rising caseload and budget of the Adult Protective Services division of the Human Resources Administration.
Adult Protective Services can aid anyone over the age of 18 found to be in need of help managing routine daily functions or at risk of exploitation or abuse, although the agency’s caseload largely skews older. IBO has examined the referrals, assessments, and types of care most typically provided through Adult Protective Services. Among our findings:
Over the five city fiscal years from 2014 through 2018, the average number of cases under care by Adult Protective Services grew 37.0 percent, from 5,406 to 7,407.
While anyone can make a referral to Adult Protective Services about someone in need of assistance, referrals most often come from government and private agencies. A review of the June 2018 cases under care by Adult Protective Services found that the most common sources of referrals were the city’s housing court and housing authority.
Among the cases under care in June 2018, the most common reasons that caseworkers determined assistance was warranted were the inability to manage finances, help needed with daily activities, and eviction. Accordingly, the three most common forms of assistance provided to clients under the agency’s care were home care, financial management, and legal intervention.
Because many referrals come from public and private agencies, clients are often already facing a crisis when Adult Protective Services staff reach out—facing eviction in housing court, for example. Increased public awareness of the assistance offered by Adult Protective Services might mean earlier referrals, potentially averting crises before they occur.
New York City’s Adult Protective Services (APS) is the largest municipal adult protective services program in the country. Mandated by New York State Social Services Law, APS assists adults who are mentally and/or physically impaired and due to these impairments:
Are unable to manage their own resources, carry out the activities of daily living, or protect themselves from abuse, neglect, exploitation or other hazardous situations without assistance from others; and
Have no one available who is willing and able to assist them responsibly.
Individuals 18 years of age or older are eligible for APS, regardless of income. With the population of city residents age 65 and over projected to swell, the need for these services is likely to increase.
APS seeks to promptly resolve the risks faced by eligible clients by developing service plans that will enable them to live independently and safely within their homes and communities. To achieve this goal, clients are offered a variety of services including but not limited to help with government benefits, case management, financial management, home care, and legal intervention.
In New York City, APS operates as part of the city’s Human Resources Administration (HRA). The total program budget for 2020 is $58 million, including a full-time staff headcount of 506. (Unless otherwise noted, all years refer to city fiscal years.) The budget includes multiple funding sources, with 28 percent of funds from the city, 26 percent from the state, and 46 percent from the federal government. In 2018, the last year with complete spending figures, total spending reached $54 million, an increase of 33 percent since 2014. The growth in spending resulted primarily from a substantial increase in the number of APS cases in recent years.
Growing Need for Services. Two key factors driving the need for Adult Protective Services are the aging of the city population and the large number of city residents who live alone. As people age they are more likely to become mentally or physically impaired. Moreover, living alone increases the chance that they will have no one to regularly look after them.
In 2010, 1.0 million city residents were age 65 or older; this group constituted 12.2 percent of the total city population. Based on current trends, the New York City Department of City Planning has projected that by 2030 there will be 1.36 million city residents 65 and over, accounting for 15.5 percent of the total population. 1Thus, it is likely that over time increasing numbers of New Yorkers will become mentally or physically impaired.
The potential impact of this demographic trend is magnified by the fact that as people age they become more likely to live alone: children grow older and move out and spouses or partners pass away. Findings from the 2013-2017 American Community Survey indicate that 49.4 percent of household heads in the city age 65 or older live alone, compared with 27.4 percent of those under 65. So as the population ages, there are likely to be more seniors living alone, and the need for APS services is likely to increase.
Who Are the Clients?
Any concerned individual who is aware of someone who might need APS services can make a referral by contacting the agency by phone or online. Based on the information provided, APS makes an initial determination as to whether the referred person appears to be eligible for services. If the initial determination is positive, an assessment case is opened. About 85 percent of referrals are accepted as assessment cases.
Clients can be in assessment for up to 60 days. A home visit is made within three business days, a standard the agency meets about 95 percent of the time according to the most recent Mayor’s Management Report; if the situation appears to be life threatening, a home visit will be made within 24 hours. During the initial home visit, an APS caseworker will review the client’s physical and mental health, living conditions, household budget and sources of income, and the status of rent and utility payments. The caseworker will also determine if there is evidence of abuse or neglect, financial exploitation, or other potential hazards. There could be several other visits by the caseworker or various specialists including psychiatrists or other mental health professionals. If it is then determined that the client is in need of ongoing APS services, a service plan is developed and an “undercare” case is opened. About 25 percent to 30 percent of assessment cases are accepted for services as APS cases under care. In order to qualify for APS services a client must meet multiple crtieria; many of those who do not meet the APS threshold are referred to other services such as rental assistance or food programs.
A Growing Caseload. In recent years, APS has seen substantial growth in referrals, assessment cases, and cases under care. On an annual basis, average referrals to Adult Protective Services increased steadily over the last decade, rising by 71.5 percent, from 1,484 in 2009 to 2,545 in 2018.2 Not all referrals are determined to warrant an assessment process, and for the first few years of this period the number of assessment cases fluctuated. From 2012 through 2018, however, average assessment cases rose from 3,050 to 4,863, an increase of 59.4 percent. The increase in assessment cases did not immediately lead to an upturn in cases under care, but from 2014 through 2018 the average number of cases under care rose by 37.0 percent, from 5,406 to 7,407.
Gender and Age.Based on Human Resources Administration data from its APS.NET client tracking system, IBO was able to analyze various characteristics of the APS caseload. All of the remaining information in this brief is based on a snapshot of APS cases as of June 2018.
In June 2018, a typical APS case under care was an older woman. Among cases where gender was identified, 59.7 percent were female. The preponderance of females likely reflects, at least in part, the longer life expectancy of women. Among those with a reported age, 9.2 percent were under 46, 41.0 percent were 46 through 65, and 49.8 percent were 66 and over. More than a quarter of all clients (26.3 percent) were over the age of 75. As discussed earlier, as people age they are more likely to develop mental or physical impairments and are more likely to live alone.
Source of Referrals. While anyone can report a possible APS case, most referrals come from governmental and private agencies. Among the June 2018 cases under care, 69.5 percent of all referrals were made by public or private agencies. Two of the most common sources of referrals were the city’s housing court and the New York City Housing Authority. This reflects the fact that many individuals are referred to APS when they fall behind on their rent or are facing eviction in housing court. Also in this category are other governmental or nonprofit social service agencies that serve needy New Yorkers and may sometimes conclude that a client is in need of the types of services APS provides. Another 8.4 percent of all referrals were made by the city’s Department of Investigation (DOI). Many of the DOI referrals are also housing related; DOI tracks eviction cases carried out by city marshals and reports them to Adult Protective Services when deemed appropriate.
While most referrals were made by agencies, 15.1 percent were initiated by individuals who knew the client, including family members, friends, and neighbors. Less frequently, the referral was self-initiated by the client (4.1 percent), or was made by an anonymous caller (3.0 percent).
Client Risk Factors. APS clients can have a variety of risk factors that keep them from being able to live independently and safely. Some clients are judged to have more than one risk factor. As of June 2018, the most common confirmed risk among cases under care was the inability to manage personal finances (38.3 percent of all identified risks). Evidence of this incapacity can include unpaid bills, eviction threats, or an overdrawn bank account. Also related to financial mismanagement, 18.4 percent of all risks concerned the threat of eviction.
The need for assistance with daily activities, which can result from a physical or mental impairment, accounted for 20.4 percent of risks. Nearly 1 in 10 (9.4 percent) of confirmed risks involved environmental hazards such as hoarding and bed bugs. Some clients were determined to be a threat to their own welfare, with 6.3 percent of risks classified as self-neglect and 1.3 percent as self-endangering behavior.
Finally, 5.8 percent of all risks involved threats to the client from other people in their lives, including financial exploitation (3.4 percent), neglect (1.7 percent), and abuse (0.7 percent). Thus, a relatively low share of confirmed risks among cases under care concerned the malevolent actions of others. This stands in contrast to APS cases still in the assessment process, among which 19.5 percent of alleged risks involved threats from others, including financial exploitation (6.3 percent), neglect (6.4 percent), and abuse (6.8 percent). This drop-off from assessment to cases under care could mean that many of the alleged threats from others are ultimately determined to be invalid or that the threat is quickly removed and the client is deemed to no longer need APS services. (It should be noted that the distribution of risks among APS clients does not necessarily reflect the level of risk among vulnerable adults in the overall population. For instance, research has shown that elder abuse is consistently under-reported.)
What Services Do Clients Receive?
Based on the risk factors confirmed during the assessment process, APS staff develop a specific service plan for each client under care. Some services are delivered directly by APS while others are provided through referrals to other agencies. The service plans from June 2018 reveal that the most commonly assigned service category was home care (18.0 percent of assigned services). Home care includes a hierarchy of services ranging from personal care aides who help with activities of daily living, to visiting nurses who provide care to clients with health issues. (The numbers mentioned here and in chart below refer to recommended services in the client’s service plan. Some clients may not follow through with some of the service referrals.)
The second most frequent service category was financial management (17.5 percent). Financial services can be voluntary or involuntary. Clients who are judged to generally be capable of making financial decisions may be assigned an informal third-party money manager or may volunteer for other types of financial management services. But clients who are determined by a psychiatrist or other mental health professional to be cognitively incapable of carrying out their financial responsibilities may be provided with involuntary financial management. In these cases, the money managers may be given control over a client’s public benefits. For example, APS can work with the Social Security Administration to appoint a representative payee to manage a client’s social security grants and use them to pay for rent and other vital expenses.
Another 15.3 percent of assigned services fall under the category of legal intervention. As with financial services, legal intervention is often involuntary. Many APS clients facing eviction in housing court are assigned a guardian ad litem, who is appointed by a housing court judge to represent the client and to help negotiate an agreement with the landlord that will avoid eviction. Once the case is over and the agreement is fully implemented, the guardian ad litem’s work comes to an end.
Some APS clients, however, are judged to be in need of longer-term legal intervention in the form of an Article 81 guardian. In these cases, APS files a Supreme Court petition asking that the court appoint a guardian for the client. Following a hearing, the judge can appoint a guardian with powers specific to that case. A guardian of the property handles decisions about the client’s finances, while a guardian of the person can make decisions about other aspects of the client’s life such as health and welfare. Some guardians are given both types of responsibilities. The judge can appoint a private guardian, but in most APS cases the court designates a community guardian organization under contract with HRA. Since legal guardianship involves some loss of personal freedom for the client, these decisions are sometimes contested.
The next largest category of services (15.0 percent) includes help with obtaining and renewing public benefits such as food stamps, Medicaid, and Supplemental Security Income grants. This is followed by mental health services such as evaluation and counseling (11.6 percent), housing services including heavy duty cleaning and home repairs (9.8 percent), and case management (7.5 percent). Other less common services include medical help, reporting crimes to law enforcement, substance abuse treatment, developmental services, and services to others in the home.
Why Are Cases Closed?
The client tracking data also identifies the reasons why APS cases are closed. In looking at closings, it is useful to examine both assessment cases and cases under care.
Clients can be in assessment for up to 60 days, during which time a determination is made as to whether the individual requires ongoing APS services; if APS services are not required, the case is closed. Among assessment cases in June 2018, the most common reason for closing the case was a determination that the individual retained sufficient mental and physical capacity (47.1 percent) or was not at risk (15.7 percent). Other reasons for closing assessment cases included: identifying someone else willing and able to take care of the client (17.1 percent); inability to locate the client in spite of multiple attempts (15.4 percent); finding that the client lived outside of the city (2.7 percent); death of the client (1.6 percent); and the client refused assistance (0.4 percent).
Cases under care can remain open for months or years, but they do not usually remain open for the remainder of the client’s life; among the cases under care closed in June 2018, only 8.7 percent were closed as a result of death. The most common reason for closing a case was identifying someone else willing and able to take care of the client (30.7 percent). This could include Community Guardian cases. After a Community Guardian is appointed by the court, APS monitors the case for three months. The case is then closed, although the role of the guardian continues.
Notably, many of the closings of cases under care were a result of finding that the client was no longer at risk (27.2 percent) or had sufficient mental and physical capacity (25.0 percent). This change in status from the assessment stage could result from the client’s receiving ongoing services from other agencies, such as home care, financial management, and public benefits. These services can help an individual to regain a sufficient level of independence so that APS monitoring is no longer necessary. Less common reasons for closing cases under care include the inability to locate a client who has moved (4.2 percent), the client leaving the city (2.5 percent), and the client refusing continuing assistance (1.7 percent).
An Aging Population, A Growing Need
In recent years APS has seen substantial growth in referrals, assessment cases, and cases under care. From 2014 through 2018 the average number of assessment cases increased by 30.6 percent to 4,863, while the average number of cases under care increased by 37.0 percent to 7,407. As a result of this caseload growth, total spending at APS increased by 33 percent to $54 million over the period.
The need for APS services is likely to continue to increase in the coming years as a result of the aging of the city population; as people age they are more likely to become mentally or physically impaired. Magnifying the potential impact of this trend is the fact that as people age they become more likely to live alone. Recent estimates indicate that about half of New York City’s heads of household age 65 or older live by themselves.
The most common confirmed risk factors among APS cases under care are financial in nature, particularly the inability to manage finances and the risk of eviction. This was followed by the need for assistance with daily activities. Consistent with these needs, the most common services offered to clients were home care, financial management, legal intervention, and help with accessing public benefits. The vast majority of clients under care are eventually judged to no longer need APS services, although many continue to receive services from other agencies.
A large majority of referrals to APS come from governmental and private agencies. In some respects, this represents a limitation on the Adult Protective Services system, since clients may become known to these agencies only after they are in crisis. For example, many referrals come from housing court, meaning that the client is already facing an eviction. Additional efforts to increase public awareness of APS services might result in earlier referrals, which could benefit many clients.3
Prepared by Paul Lopatto
1New York City Department of City Planning, New York City Population Projections by Age/Sex & Borough, 2010-2040. December 2013
2The Human Resources Administration reports referrals, assessment cases, and undercare cases on a monthly basis. The averages reported in this section are for the 12 months of that fiscal year.
3The New York City Department for the Aging has recently expanded multi-disciplinary teams in all five boroughs; these teams include emergency room personnel who could be a source of early stage detection and referral.
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