Behavioral Health Services Are Key to Supporting At Risk Older Adults

  As a regular feature of this blog, we highlight our professional partners who have committed their knowledge, passion, skills, and time to protect older adults in their community.

Cassie Cramer, Somerville Cambridge Elder Services

photo credit:  Stephanie Becker

What do you do professionally and do you ever encounter elder abuse and self-neglect issues in your work?

I am a peer advocate, co-chair of the MA Aging and Mental Health Coalition and social worker in a mental health program at Somerville Cambridge Elder Services. Before I started this position, I worked in Elder Protective Services for 5 years. My background in elder abuse, neglect and self-neglect led me to the position I have today, providing longer-term support to people and advocating for the development of these supports statewide.

 How do behavioral health issues play a role in elder abuse and neglect?

In Protective Services I learned a lot; specifically I learned about when and why things go wrong. I found that by far, our biggest systematic failure was the lack of accessible (in-home) mental health services for older adults. Without on-going support in the community, people cycle through Protective Services- chronically “at-risk” and facing bleak outcomes.

            In Protective Services, I saw first-hand how behavioral health conditions can lead to poor self-care.  Poorly monitored diabetes or blood pressure can cause catastrophic health problems. Behavioral health conditions can cause isolation, cutting ties with would-be caregivers and social supports. Substance use among family members is often underlying abuse, exploitation or neglect.  Substance use and other behavioral health conditions among older adults can lead to problems with housing and risk of homelessness. I found that well-meaning providers are often quick to defer to institutionalization when older adults are facing crisis- people frequently called and expressed their view that an individual be “placed somewhere” because they “didn’t belong in the community.” 

            My observations are reflected in statistics: untreated behavioral health conditions among older adults are associated with higher health care use, development of preventable health problems, lower quality of life, caregiver stress, suicide and high rates of institutionalization.  Studies have shown that failure to provide mental health treatment in the community increases the likelihood of nursing facility admission by a factor of three, and that institutionalization is likely to occur at a much younger age.  Older adults with behavioral health conditions face many barriers to accessing traditional supports including lack of transportation, cost of co-pays, isolation, high levels of stigma around mental health, ageism among providers, and difficulty coordinating appointments due to co-occurring cognitive conditions, like dementia. For these reasons, older adults are least likely to receive mental health support.

What do you think is the best way to prevent elder abuse and self-neglect?

The MA Aging and Mental Health Coalition advocates for the development of a statewide network of in-home behavioral health supports, including case management, peer support, and therapy.  In the small pilot programs scattered across the state, we have already begun to see the effectiveness of these supports. In the program where I work, we are able to help people at risk of homelessness by taking referrals for people in the early stages of eviction, acting as a liaison with housing management and developing creative solutions to help stabilize tenancy. We help people in medically inappropriate housing, no longer able to climb the stairs of a walk-up apartment, move into accessible units.  We help people who are not receiving any medical care start seeing a primary care doctor or enroll in managed care programs, receiving in-home support from a nurse case manager. We also have an older adult peer specialist on staff who helps people who are isolated, often conducting visits in a local cafe or the library. Unfortunately these budding programs and success stories represent what is possible, rather than a reality for most people, who do not have access to in-home mental health support. A statewide network of in-home behavioral health supports is needed to ensure that all people- regardless of age or a mental health condition- have the opportunity to live full healthy lives in the community.

Is there anything else you would like to add about yourself or your work?

The Aging and Mental Health Coalition meets monthly in Boston and is open to anyone interested in joining our advocacy efforts. If you would like more information, you can contact me at or 617-628-2601 x3089



Access to Healthcare = Elder Abuse Prevention


One of the most crucial tools of elder abuse prevention is access to quality, affordable, health care.  In 2010 the Affordable Care Act (ACA) expanded health care access to over twenty million people across the country including many older adults.  This includes increased access to wellness visits; long term supports and services (LTSS); substance abuse treatment; increased access to behavioral health services; and much more.  The Republican controlled Congress, along with President Trump, have made it their mission to repeal the ACA and to radically change Medicaid.  While there is great uncertainty about how or when any changes will take place, there is no doubt about the positive impact that increased access to affordable healthcare has on the lives of older adults.

How Does Access to Healthcare Intersect With Elder Abuse Prevention?

Access To Medical Professionals – The ACA greatly increased access for older adults to healthcare providers.  This means they now receive routine monitoring for physical, cognitive, and functional problems – all of which can assist in identifying and preventing elder abuse.

The Opioid Crisis  – I have written several prior posts on how the opioid crisis has adversely affected so many older adults in Massachusetts and their younger family members as well. One Republican plan would end substance abuse and mental-health coverage that’s now used by at least 1.3 million Americans in the expanded Medicaid program.  This is a huge mistake –  treatment options are already difficult to come by and this particular change will only increase the costs of the epidemic for some of our most vulnerable citizens.

Self Neglect/Behavioral Health Services – Many older adults who suffer from self neglect are at great risk of losing their home, their income, or face increased risks to their safety or health.  Often at the root of self neglect situations are untreated mental health issues.  It is difficult now for many older adults to receive quality, accessible, behavioral health services.  The threatened cuts would greatly exacerbate this problem and leave many very vulnerable elders with inappropriate, unsafe, and much more costly options such as homeless shelters, nursing home placement, or hospitalization.

LTSS – An accessible LTSS system is critically important in preventing elder abuse.  LTSS are often what allows an older adult to stay in their home safely, to receive needed help such as chore services or home care services, and to keep them out of more costly institutions like nursing homes.  Medicaid is the primary payer of LTSS, covering approximately two-thirds of all LTSS costs nationwide. Proposed changes to the Medicaid program would put access to LTSS at risk and inevitably lead to less healthy and much more costly outcomes for many older adults.

Expanded access to healthcare through the ACA, along with the many other positive changes to improve the quality of healthcare and produce better outcomes for patients, has been an essential link in promoting elder justice.  We don’t know what future changes to the ACA and Medicaid will entail, but it is clear that decreasing access to basic health care services will have a devastating impact on older adults and hinder ongoing efforts to prevent elder abuse.

Legal Fellows Fight Elder Abuse Head On

In September 2016, the Elder Abuse Prevention Project of Greater Boston Legal Services welcomed two new Elder Justice Americorps fellows, Dvora Walker and Sheba Varughese. Ms. Walker and Ms. Varughese are a part of the Department of Justice initiative to promote elder justice. There are 25 such fellows serving across the United States, all of whom assist low-income elders and work to eliminate elder abuse and exploitation.

Dvora Walker received her J.D. and Graduate Certificate in Human Rights from the University of Connecticut School of Law. She acted as a caretaker for her grandmother and great aunt in high school, which inspired her passion for elder justice and enabled her to relate to and have compassion for elders. Dvora primarily works on cases involving financial exploitation, evictions, and complex familial dynamics. She has been an extremely valuable asset to our Project in a relatively short period of time.  She has worked with several self neglecting clients who were at great risk of losing their housing and was able to stabilize and preserve their affordable housing and help them avoid homelessness.  She recently helped an elderly victim of decades of domestic violence renew a restraining order which increased her security and gave her peace of mind.  She is a great advocate who loves meeting with elders, and engaging with them one-on-one and who feels deeply that elders deserve respect and believes that legal advocacy can be essential in allowing them to age with dignity. Ms. Walker has previously worked as an LGBTQ Rights and Women’s Rights advocate and sees Elder Justice as another critical component of the social justice movement. dv

Dvora with former Attorney General Loretta Lynch

Sheba Varughese received her J.D. from New England Law | Boston. She developed her commitment to public interest work in law school, where she had the opportunity to interact with victims of abuse, abandonment, and neglect. Her empathy and fervent spirit allows elders to feel secure and creates a relationship of trust and reliability. Sheba has also been a very valuable addition to the Project with her focus on SSI benefits eligibility, termination, and allegations of overpayment, as well as inhospitable living conditions, such as unauthorized nursing home discharges and failing to meet public housing protocols.  Sheba’s goal is to provide elders with support and a solid source of income for their basic necessities. Her primary objective is to promote inter-generational interactions, where elders feel nurtured and appreciated for their life’s hard work. Sheba believes social isolation negatively affects both mental and physical health, and strives to give back to the local community. 


Sheba with former Attorney General Loretta Lynch

We are so fortunate to have Dvora and Sheba working with us in our efforts to stamp out elder abuse!

Elder Homelessness = Elder Abuse

If you follow this blog, you know that the Elder Abuse Prevention Project is highly invested in community partnerships as the most effective means of combating elder abuse.  We have spent the past year highlighting different community partners who truly are the “Heart and Soul of Elder Abuse Prevention.”  It is fitting that we end 2016 with one more incredibly valuable partner whose work over the last several decades with homeless and at risk elders in Boston has been truly exemplary  –  Eileen O’Brien, Director of the Boston Medical Center’s Elders Living at Home Program.


What Is the ELAHP?

Since December 1986, Boston Medical Center’s Elders Living at Home Program (ELAHP) has been providing intensive case management services to homeless and at-risk individuals age 55+, with the goal of helping them transition to and maintain safe, affordable permanent housing.  Our goal is to provide supportive services that build on the individual abilities of elders and help them to overcome barriers to stable housing. Thirty years later, we have served more than 4,000 of these individuals. In the vast majority of these cases, we were not only able to help them resolve their housing crisis, but also improve their health and support them in living full and meaningful lives. I am the Director of ELAHP, and I have worked professionally in the field of aging for 35 years.

How Does Elder Abuse Contribute to Elder Homelessness?

There are a number of reasons why older adults face housing instability. Financial hardship and declining health are two of the biggest causes, and often these two factors combine. A third factor, which has become even more common in the past several years, is elder abuse. Elders can, and many times do, lose their housing because of abuse or exploitation by a caregiver or family member. This happens due to financial exploitation—older adults are unable to pay their bills, including rent, mortgage or utilities because someone is stealing from them or in some way financially exploiting them. In other instances, family members or others may move into the homes or apartments of their elderly relatives, not only jeopardizing their safety and well-being, but endangering their tenancies by causing lease violations. This is one of the ways that the opioid crisis has affected older adults. Adult children and grandchildren who become addicted to heroin or other similar drugs prey on older relatives financially, and/or create serious problems for them by conducting illegal activities in their homes and apartments. This is a very overlooked aspect of the crisis, but one that has serious consequences for older adults’ housing stability, health and well-being.

How Do You Focus on Prevention?

In recent years, ELAHP has put a greater emphasis on homelessness prevention, so it was a very logical next step to get involved with some of the efforts to prevent elder abuse. Greater Boston Legal Services has taken a leadership role in developing community coalitions in Boston, where we are based and do most of our work, and Malden, where we hope to expand in 2017. The coalitions are designed to meet each community’s needs and build on each community’s strengths.

The coalitions are important because they raise awareness of the problem of elder abuse, and that is a key part in preventing it from happening. Elder abuse is not a very well understood issue, often because there may be stigma or shame attached to it. By increasing understanding of the problem, and helping to define it for all members of the community—including older adults themselves—we can begin to address what causes it, and how to prevent it. The coalitions have been effective because they involve not just the “usual suspects” of elder service providers, but also other community members such as law enforcement, local government and businesses. If all of these stakeholders better understand what the problem is and how to recognize it, and are educated about the resources available to elders who may be at risk, we can make significant progress towards preventing elder abuse in these communities.

Elder abuse can have significant consequences, including homelessness. By educating elders, their families and caregivers, and members of the community about it, and what they can do to prevent it or stop it, we can make a difference in the towns and cities where we live and work. There are many things that we cannot prevent, but elder abuse, and homelessness that results from it, are not among those things. Elders should not be faced with living in emergency shelters or on the streets for any reason, but particularly not when that happens due to abuse or neglect.


It’s Medicare Open Enrollment – Watch Out For Scams!


October 15, 2016 is the beginning of Medicare open enrollment which is a time period when Medicare beneficiaries can join plans or switch plans.  This means upwards of 55 million older adults and younger disabled individuals who are Medicare beneficiaries have the opportunity to choose new or different medical coverage.  This also means that open enrollment is a prime time for Medicare scams.  These scams use a trusted and valued program – Medicare – to gain unauthorized access to beneficiary information which can result in identity theft or financial exploitation.

What do these scams look like?

*             A beneficiary gets a phone call from someone claiming to work for Medicare who states that new Medicare cards are being issued or that the beneficiary’s file must be updated. The caller asks for the Medicare card number which is usually a person’s Social Security number and/or financial information.   Disclosure of such information can lead to identity theft or unauthorized withdrawals from a person’s bank account.

*             A phone call from someone who states that it is open enrollment time and tells the beneficiary that they MUST switch plans or risk losing their current coverage.  Beneficiaries who fall for this scam are often enrolled in a plan that doesn’t suit their needs or allow them to see their doctor or get their medications covered.

*             Phone calls from people saying they’re from your doctor’s office, other health care providers, or suppliers who ask for your Medicare number in exchange for free equipment or services.

*             A person comes to your door claiming to be from Medicare and tries to sell supplies by asking for a Medicare card and/or credit card. Medicare does not send representatives to people’s homes to sell products or services.

Helpful Tips

It is important to know that Medicare will never call or show up at someone’s door or ask for personal/financial information via email. 

Perhaps the most important information that beneficiaries need to safeguard is their Medicare number.  All Medicare beneficiaries receive a Medicare number and card automatically upon enrollment – these cards do not expire and Medicare will not call beneficiaries to offer a new card or request information in order to issue a new card.



Domestic Violence = Elder Abuse


October is Domestic Violence Awareness Month.  One of our most important community partners in our Cambridge Elder Abuse Prevention Coalition is Assistant Director Ronit Barkai and the staff of Transition House.  Ronit is yet another example of community members who are the “Heart and Soul of Elder Abuse Prevention.”




What do you do professionally and do you ever encounter elder abuse issues in your work?

My name is Ronit Barkai and I am the Assistant Director of Transition House, located in Cambridge (MA). Transition House is one of the oldest domestic violence agencies in the country. The agency started out in 1976 and was very much a grassroots organization, staffed by volunteers and greatly connected to the feminist movement and activism of those days. The majority of our work up until about 4 years ago was sheltering victims of violence that fled to us and who were not local. About 14 years ago, Transition House began opening a variety of housing programs that offered more long term housing options for people fleeing domestic violence (a Transitional Living Program and Supported Housing Program – a total of 12 apartments that house 17 people). The intent was to allow a longer time for survivors to get back on their feet following domestic abuse. I have worked at Transition House for 14 years and as far as I know, and recall, very few elder victims were utilizing our shelter and other housing services because the option of leaving everything behind at an older age is very intimidating. These facilities usually cater to a younger population, have plenty of younger children on-site, and are limited in what medical support they can offer.

Thankfully in the past 4 years, with the help of the Cambridge Housing Authority, the City of Cambridge, and the Massachusetts Office of Victim Assistance (MOVA), we were fortunate enough to expand our work and assist those experiencing domestic violence in our own community (Cambridge) with the opening of the Community Program. Transition House looks at domestic violence beyond what happens to a (younger) heterosexual couple in an intimate relationship. Our work recognizes that domestic violence happens between family members living in the same home (like father and daughter; mother and son). We also assist the GLBTQI community and have housed male and transgender victims of domestic violence in our programs. Our work around elder abuse expanded around the same time we opened the Community Program. We started attending workshops that brought us together with those that work with elders like Somerville-Cambridge Elder Services and brainstormed how we can be of help to elders experiencing all forms of domestic violence and abuse. It was also about 4 years ago that Transition House started a very close collaborative relationship with the Cambridge Council on Aging and the Senior Center. Through this collaboration, we presented workshops on domestic violence to both Senior Center staff and participants. The outreach work and trainings started to grow partnerships. We started getting more referrals to assist elders experiencing domestic violence and offering creative ways to assist those that struggle. We are proud to collaborate around safety planning, risk assessment, obtaining restraining orders and accessing creative housing options (such as emergency vouchers that are an option for victims of domestic violence). Our services are voluntary and confidential. We understand how difficult and scary it is for someone (especially if elderly) to disconnect from an abusive partner, family member or even care-taker. We understand and try and tackle all types of abuse, including financial, emotional and sexual abuse. We have seen elders not have access to their medication, appropriate clothing, and medical care. We have to look beyond physical abuse to understand that someone is experiencing domestic violence. Financial abuse and isolation are so very common with elders. The more fragile and limited in mobility they are, the more we fear that they have no access to alternative, safer living options. Thankfully, through a recent grant from the Tufts Health Plan Foundation, we will be able to grow our services and offer more direct advocacy and counseling to elder victims of domestic violence.

What drew you to the Cambridge Elder Abuse Prevention Coalition?

We see and understand that baby boomers are aging. I have heard it referred to as the “silver tsunami” about to flood all of the service providers. In my mind, every domestic violence agency needs to be at the table working together with providers to ensure that elders get the appropriate care and protection they need. In some cases, it’s only when a care provider enters the home that the big secret of domestic violence is finally brought to the surface. It could be that after 30-40 years of domestic violence, there is someone finally coming in and seeing what is truly happening in the home and who can offer safer options. I greatly enjoy being part of the coalition and it enables me to network and reach out to so many providers all working with the same goal.

What do you think is the best way to prevent elder abuse/intimate partner abuse in later life?

I think we should collaborate with as many providers as possible on increasing outreach and awareness that domestic violence does not stop as we age. In some cases, it increases with age, and in others, it just takes on different forms and facets. I also hope we can put together materials that are targeted to elders – how many posters about domestic violence have you ever seen include an image of an older adult?  This material should be targeted to raise awareness that elder abuse/intimate partner abuse exists and what it can look like, as well as, offering options to those already struggling with this kind of abuse.

Is there anything else you would like to add about yourself or your work?

I find it a great privilege to work in this field. I greatly admire people’s courage when leaving everything behind. I am proud to be part of an agency that is able to offer flexible options for those that want to make a change or break away from domestic violence. In many cases, people are leaving a person that they may still love. Nothing is simple –  domestic violence impacts so many parts of a person’s life so we should not judge those that choose to stay. I also greatly enjoy the spirit of Cambridge in knocking down silos and working together to find safety and peace for those that struggle with elder/intimate partner abuse.






Loneliness and Elder Abuse

In trying to prevent elder abuse of all types, including financial exploitation, it is crucial to understand why older adults are targeted and what risk factors increase the chance of an elder being abused or exploited.  Multiple studies have found that loneliness and isolation can significantly raise the risk of elder abuse. Elders may be isolated due to health related issues; the death of family and friends; mobility difficulties; lack of transportation; living alone; or the deliberate acts of an abuser.  In 2014, according to the U.S. Census Bureau, 46 percent of women 75 and older and 23 percent of men that age lived alone. As our longevity boom continues and older adults in this country continue to live longer, we will have an ever growing percentage of our population who live alone and are isolated.


How does loneliness play a role in elder abuse?

Loneliness and isolation tend to make elders more vulnerable to being taken advantage of.  This can happen when a “new best friend” comes on the scene and takes advantage of a lonely elder’s desire for companionship. The new friend may exert significant influence over the elder which can create easy access to financial and other important decision making.  Loneliness may also make an elder vulnerable to a scammer on the phone who targets older people just craving someone to talk to.  Phone scams, including romantic or “sweetheart scams,” are rampant and can result in financial devastation for older victims.  Isolation can also occur when a perpetrator known to the elder – a family member or friend – deliberately isolates the elder to better exploit them. In order to keep the abuse hidden from others, perpetrators may monitor the elder’s communications, block family and friends from access with the elder, attend medical appointments or meetings with financial institutions with the elder, and create obstacles for the elder to socialize outside the home.

All elder abuse prevention efforts must include a plan to address the social isolation that many older adults in a community experience.  How can we increase the possibility for social connections in our communities – even to the most socially isolated elders?  Here is a link to a recent story on the “Epidemic of Loneliness” and an innovative program in Great Britian that attempts to address this critical issue.