Ongoing Repercussions of COVID-19

The initial COVID-19 pandemic and subsequent public health measures dramatically impacted Adult Protective Services (APS), requiring rapid adjustments. Our goal was to describe challenges for APS and strategies developed to respond. We conducted six focus groups and seven interviews during March–April 2021 using a semi-structured topic guide, with 31 participants from APS leadership, supervisors, and caseworkers in New York City, a community hard hit by the initial COVID surge. Data from transcripts were analyzed to identify themes. Participants identified challenges faced by APS (e.g., clients less willing to engage with APS, inability to perform necessary job tasks remotely, and low staffing levels) as well as strategies APS used in response (e.g., increasing collaboration with other community-based programs and service providers, enabling remote court hearings through technology and in-person facilitation, and ensuring staff had access to personal protective equipment). These findings may inform APS planning for future large-scale societal disruptions.

What this paper adds • Improved understanding of the challenges Adult Protective Services (APS) faced in a large city during the initial surge of the COVID-19 pandemic • Description of 30 formal and informal strategies APS used to overcome pandemic-related challenges, including focusing on maximizing client engagement while maintaining client and worker safety as well as allowing for remote work and supporting staff • Insight about the ability of APS to rapidly adjust during an unprecedented crisis impacting clients and staff Applications of study findings • Our work highlights the importance of using technology, flexibility, and collaboration to overcome challenges with providing services during a pandemic that rely on in-person meetings with clients as well as the importance of supporting staff • APS in other communities may consider incorporating strategies developed by New York City to manage ongoing pandemic-related challenges in anticipation of future societal interruptions • Other community-based agencies may learn from what APS has done and can become better community partners Introduction Older adults who are experiencing or at risk for elder abuse, including physical abuse, sexual abuse, neglect, verbal/ emotional/psychological abuse, and financial exploitation, have been particularly vulnerable during the coronavirus disease 2019 (COVID-19) pandemic (Han & Mosqueda, 2020;Makaroun et al., 2020). This abuse can have grave repercussions, including increased depression, exacerbations of chronic illness, and mortality (Lachs & Pillemer, 2015). During COVID-19, increased isolation from people outside the household, extended periods of close contacts with potential abusers in the same household, less access to community-based services and professional caregivers, and increased financial strain have contributed to increases in this already common phenomenon (Elman et al., 2020). While as many as 10% of community-dwelling older adults suffer from elder mistreatment in a typical year, one study found that more than 20% have experienced it during the pandemic (Chang & Levy, 2021).
A critical component of the response to elder mistreatment in the United States is Adult Protective Services (APS). State APS programs are responsible for investigating cases of potential elder mistreatment in the community and coordinating provision of necessary services to older adults experiencing abuse. Some but not all state APS programs also serve adults aged ≥18 with mental and/or physical impairments. A cornerstone of the APS investigation and response under typical circumstances is a face-to-face home visit to meet with a vulnerable adult (Administration for Community Living, 2020). In fact, in many states, APS caseworkers are mandated to make an unscheduled home visit within a specified timeframe after receiving a referral (New York State Office Of Child and Family Services, 2022).
The initial surge of the COVID-19 pandemic dramatically impacted APS' ability to conduct investigations and respond, requiring the program to quickly adapt (Elman et al., 2020;Teaster & Kebede, 2020). In many communities, APS committed to continuing to attempt to visit adults in person in their homes when possible while trying to ensure safety for staff and clients. A recent national study with a survey of state administrators and interviews with APS staff reported on aspects of how a broad range of APS programs responded to the pandemic (Teaster & Kebede, 2020). We sought to qualitatively explore in greater depth how the large, highly functioning, and well-funded APS agency in New York City, which serves a racially/ ethnically diverse population that was particularly hard hit by the initial COVID-19 surge, quickly adapted. We hoped to gain insights from which other communities might benefit.
Informed by previous research on the dynamics of organizational adaptation during times of social disruptions (Uitdewilligen et al., 2021), we were guided by the event systems theory, which examines how event-induced crises may facilitate and shape collective responses across multiple hierarchical organization structures, ranging from leaders to supervisors/managers to frontline workers (Morgeson et al., 2015). This event-oriented perspective provides a valuable lens to understand how events shape adaptations, with organizational challenges and responses conceptualized as a complex and dynamic adaptive process. The fast-evolving COVID-19 pandemic clearly fit the three criteria of an event with a strong and enduring influence: novel (i.e., different from prior routines), disruptive (i.e., great magnitude of change), and critical (i.e., demand action and reprioritization).
Our goal was to explore the experiences and perspectives of APS workers in frontline and leadership roles during the initial pandemic surge. We focused on: (1) challenges for APS conducting their work during the surge and (2) strategies they developed to effectively respond.

Study Design
We conducted a qualitative study using focus groups with APS caseworkers and supervisors as well as one-on-one interviews with members of APS leadership in NYC to improve understanding of their experiences investigating potential abuse and providing services during the initial surge of the COVID-19 pandemic. Focus groups are ideal for examining the complexity of a group's perspective on a topic to identify possible shared experiences or opinions (Mansell et al., 2004). Similar approaches have previously been successful in exploring APS attitudes (Chang & Greene, 2001). We conducted focus groups of caseworkers and supervisors in an attempt to get a broad range of perspectives and because we recognized that focus groups often facilitate additional information beyond what might be obtained from a series of interviews. We did not include supervisors and caseworkers in the same focus groups given that we wanted to promote frank and open discussion. We chose to conduct one-on-one interviews with leadership because we wanted to understand their perspectives and choices in more depth and because it was challenging to schedule a focus group that multiple members of the NYC APS leadership could attend.
We developed semi-structured guides containing open-ended questions for focus groups and interviews. Topics explored included: changes in reporting of abuse due to COVID-19, differences in the types of abuse identified, innovative strategies/ changes in protocol, new challenges, and support of leadership. Prompts included: In your experience, how has COVID-19 impacted the way in which APS investigates and intervenes in cases of elder mistreatment? What are the biggest new challenges? Have you been using any new or different strategies for investigation or intervention during the COVID-19 outbreak? The entire guide is available as Online Supplemental Material. Though data collection occurred nearly 1 year later, participants responded primarily about their experience during the initial surge from March to June 2020. During this period, New York City was an epicenter of the global pandemic. The entire city was locked down, with schools and most businesses closed. Hospitals were overrun with critically ill patients, there was a shortage of Personal Protective Equipment (PPE), and neither vaccines nor therapeutic medicines were yet available. The complete focus group and one-on-one interview topic guides were pilot-tested.
This study was approved by the Weill Cornell Medicine Institutional Review Board as well as by the NYC Human Resources Administration (NYC HRA), which oversees APS.

Participants and Research Setting
A convenience sample of caseworkers, supervisors, and APS senior leaders was obtained, with potential participants invited by APS leadership via email. All potential participants were employed by NYC HRA in any of the five boroughs in NYC. Participation was voluntary, and several of those approached declined to participate because of scheduling issues or did not respond to e-mails. The focus groups and interviews were facilitated remotely using Microsoft Teams given concerns about congregation in in-person groups during the ongoing pandemic. Nobody other than the research team and participants was present during the focus groups or interviews. Verbal informed consent was obtained from all participants, with this recorded as part of the focus group/interview transcripts. This approach to informed consent was approved by the Weill Cornell Medicine Institutional Review Board.

Data Collection
We conducted six semi-structured focus groups and seven oneon-one interviews, with 31 total participants, from March to April 2021. The caseworkers had a median of 3.5 years of experience, the supervisors 7 years, and APS leaders 26.5 years. Among all participants, 69% were female. The duration of focus groups and interviews ranged from 37 to 56 minutes. Each of the sessions was moderated by one or two of the authors (T.R. and A.E.), the former a male emergency medicine physician and the latter a female social worker at Weill Cornell Medicine/ NewYork-Presbyterian Hospital. Both have extensive experience collaborating with APS, knowledge of elder mistreatment, and qualitative research expertise. The purpose of the study and the moderator(s) was introduced in a detailed and standardized fashion prior to each focus group or interview. No one other than the research team and participants were present. Sessions were conducted during the work day. Participants were not given any payment for participation. Participants agreed for the sessions to be audio recorded and professionally transcribed. Transcripts were not subsequently shown to participants. No additional field notes taken during the interviews or focus groups were used in the analysis. No repeat interviews were conducted.

Data Analysis
Focus group and interview transcripts were reviewed in detail and discussed by the investigative team. They were analyzed and coded by three authors (A.E., E.G., T.R.) using thematic analysis (Braun & Clarke, 2006). We used a combination of deductive and inductive coding, with a set of codes developed a priori and additional codes emerging from the data (Fereday & Muir-Cochrane, 2006). A priori codes were identified during several meetings based on the investigative team's experience working closely with APS before and during the pandemic and extensive experience with similar qualitative analyses examining assessment and management of vulnerable adults by professionals (Rosen et al., 2017(Rosen et al., , 2018. Hierarchal codes focused on challenges with client interaction/service delivery, transition to remote work, and workforce issues as well as strategies that APS used to address these challenges. Analysis began while focus groups were still ongoing and was conducted iteratively. All discrepancies were resolved using negotiated consensus (Bradley et al., 2007). We did not use qualitative analysis software but reviewed transcripts within Microsoft Word and tracked themes in Microsoft Excel. We assessed data saturation as a research team throughout the process by discussing whether any new themes were emerging. Data saturation was achieved before completion of all focus groups/ interviews. The results of the coding and themes were discussed and reviewed with the entire investigative team. Participants did not provide feedback on the findings. We used the Consolidated Criteria for Reporting Qualitative Research to guide collection, analysis, and reporting of the data (Tong et al., 2007).
The large, multi-disciplinary study team included clinical social workers, an emergency physician, a geriatrician, social scientists, and epidemiologists. Many work in a hospitalbased elder abuse response team based in New York City that routinely interacts with APS, but none of the authors have ever worked for APS. Also, multiple authors do not work in New York City, minimizing the likelihood that the bias of a single author's perspective dramatically influenced data collection, analysis, or reporting.

Occurrence of Elder Mistreatment During COVID-19
APS caseworkers, supervisors, and leadership reported believing from their experience that abuse was happening more frequently during the pandemic. Particularly, APS thought physical and financial exploitation may be occurring more often.
Supervisor #2: Families are isolated together, and…household dynamics are reaching…this breaking point. We've actually gotten about four or five [police] referrals. That's something that I've never seen. Supervisor #7: [People] have nowhere to go, so they're moving in with parents and grandparents. They're losing their jobs. They don't have financial resources and…they're starting to…eat [into] whatever resources grandma has. A lot of times grandma's income is social security and food stamps…not enough for herself. This increased occurrence was primarily attributed to stress placed on family members and isolation of the vulnerable adult due to the pandemic. Not only were clients typically initially unable to see family or friends due to stayat-home orders, but they also no longer received services from community agencies who may have been able to provide surveillance. In some instances, home health aides were also unable to come or vulnerable adults canceled these services due to illness or fear of illness.
Caseworker #6: I've had certain clients leave…home health aide agencies, because the staff members weren't vaccinated or they just didn't feel comfortable having somebody in their home.
Their perception of the frequency of mistreatment occurrence during the pandemic informed participant perspectives about the challenges and strategies developed.

Challenges Faced by APS During the COVID-19 Surge
Participants identified nine major challenges in three major thematic categories: six issues with client interaction/service delivery, two issues with transition to working remotely rather than in the office, and one issue with workforce (shown with representative quotations in Table 1) Client Interaction/Service Delivery. Issues with client interaction/ service delivery included challenges in four sub-categories: clients less willing to engage with APS, difficulties communicating while conducting assessments, concerns about risks of APS worker COVID exposure during client interactions, and additional responsibilities to cover for other community-based organizations.
Participants reported that clients were less willing to engage with APS during the initial pandemic surge. A key reason for this was client concern for COVID exposure, but APS workers also thought that this may have been used as a convenient excuse.
Supervisor #13: Elderly are refusing us access, citing the pandemic. What's changed is the clients are using the pandemic as an excuse not to gain access. In the past, they would say, oh, today's not a good day, I have appointments, oh, and then we'd try them again…But now it's, "Oh, it's the pandemic, no, I don't want to be exposed. Can't let you in." Another reason for reticence to engage was that clients were concerned that APS might separate them from a caregiver on whom they depended.
Leader #3: Most of our elders are isolated during this time….They're alone….They have no one except probably whoever their caretaker….or…exploiter is. So, during this time, they feel lonely and isolated.
APS reported difficulties communicating with clients while conducting assessments either in person (because of the absence of in-person interpreters) or via telephone (because of clients' difficulties using technology, hearing impairment, and other factors). APS acknowledged concerns about risks of COVID exposure of APS workers themselves during client interactions, particularly given that knowing whether another person was infected and contagious was difficult. APS also reported needing to do home visits/wellness checks during the initial surge on behalf of other community-based programs which were no longer going to client homes even if older adults did not meet APS referral criteria.
Caseworker #6: You know sometimes different agencies will refer to APS clients….because they know that we make home visits…We always have since the pandemic broke, and they may not. So they may say, "We can't do our job so let's give it to APS to go and check it out in the home…" Transition to Remote Work. Issues with transition to working remotely rather than in the office included the need to set up, use, and rely on technologies and to develop new protocols for interaction and workflow.
APS also struggled with inability to perform some necessary job tasks remotely, including review of mail.
Leader #5: We would receive the client's utility bills whether from Con Edison, gas, telephone, and so on, which required my staff to open the bill. To be in the office. The bill comes to our P.O. Box. It gets delivered to our office, and we have to open the mail to make sure that we're paying the actual amount of the bill for each client and enter in our system. This was a challenge.
Workforce/Staffing Levels. APS also reported that workforce/ staffing levels were a significant challenge due to attrition from quitting, retirement, and prolonged illness.
Supervisor #13: Unfortunately, we are down to a skeleton crew. Because of COVID, many people have left the city, retired, or quit or found something else.

Strategies Used by APS During the COVID-19 Surge
During the initial pandemic surge, more APS work was done remotely, but in-person services continued throughout. Participants reported 30 formal and informal strategies adopted during the COVID-19 surge to address some of the challenges described above. These strategies were in two major domains: improving client assessment and allowing for remote work/ supporting staff. Participants described 13 strategies to improve client assessment, focusing on maximizing client engagement while maintaining client and APS worker safety (shown with representative quotations in Table 2). These

Client interaction/service delivery
Clients less willing to engage with APS Clients attributing concern about COVID-19 exposure as an excuse to refuse APS caseworkers access to their home to make an assessment Supervisor #13: Elderly are refusing us access, citing the pandemic. What's changed is the clients are using the pandemic as an excuse not to gain access. In the past, they would say, oh, today's not a good day, I have appointments, oh, and then we'd try them again…But now it's, "Oh, it's the pandemic, no, I don't want to be exposed. Can't let you in." Reticence of older adults, who have increased dependence on the abuser during the pandemic for care and social contact, to engage with APS given concerns that interventions may increase isolation Leader #3: Most of our elders are isolated during this time….They're alone….They have no one except probably whoever their caretaker…or…exploiter is. So, during this time, they feel lonely and isolated.

Difficulties conducting assessments
Lack of in-person interpreters increases difficulty of communication/assessment Caseworker #8: Interpreters are no longer able to come out to do a visit with us. We do have a phone number where we can get an interpreter, but that also poses a challenge because of the social distancing.
Difficulty assessing for abuse or well-being on the telephone because of: • Inability to comprehensively evaluate • Challenges building rapport • Client inability/unwillingness to interact with technology • Hearing impairment Caseworker #1: They're…in a really bad state, and you wouldn't know that because you're only talking to them on the phone.
Leader #1: It's difficult to interview someone who is possibly getting abused face-to-face. Imagine…on the phone…It's almost like when you know you have to smile and put this person at ease. Over the phone, you…have a smile on your face, but they can't see the smile. Caseworker #8: A lot of times, people…don't…want to speak over the phone. They're like…"I hate these things, this new technology. You young folks are always…looking for something easier." Concern about risks of APS worker COVID exposure Concern that APS caseworker may be exposed to COVID-19 when performing in-person assessments and interacting with clients Caseworker #1: We try to detect if they [clients] have symptoms, but…people…can lie, people can forget, people can…go to a store and be exposed to someone else and not know it…You're rolling the dice every time you go out there.
Additional responsibilities to cover for other community-based organizations APS asked to do home visit/wellness checks on behalf of other community-based programs which were no longer going to client homes even if older adults did not meet APS referral criteria Caseworker #6: You know sometimes different agencies will refer to APS clients….because they know that we make home visits…We always have since the pandemic broke, and they may not. So they may say, "We can't do our job so let's give it to APS to go and check it out in the home…" Caseworker #5: Sometimes…[there] wasn't even a risk associated. It was just…wellness visit.
With APS staff transitioning to remote work Need to set up, use, and rely on technologies which many staff members did not have access to or familiarity with, and to develop new protocols for interaction and workflow using technologies Leader #4: Not everyone is computer savvy, so then we have to figure out how do we strategize those that are not computer savvy…how to get them the assistance…We do have some challenges…where folks are just not that savvy to be able to create the file, turn it into a PDF, save it on their desktop, and then forward it as an attachment.
Inability to perform some job tasks remotely, including review of mail Leader #5: We would receive the client's utility bills whether from Con Edison, gas, telephone, and so on, which required my staff to open the bill. To be in the office. The bill comes to our P.O.Box. It Box. Itgets delivered to our office, and we have to open the mail to make sure that we're paying the actual amount of the bill for each client and enter in our system. This was a challenge.
Workforce/staffing levels Attrition/loss of staff due to quitting, retirement, illness Supervisor #13: Unfortunately, we are down to a skeleton crew. Because of COVID, many people have left the city, retired, or quit or found something else.

Client assessment
Making in-person assessments as safe as possible Adding pre-screening questions at intake before a home visit to assess COVID-19 risk/exposure Leader #6: They give you time to conduct your pre-investigation, which now includes trying to determine whether or not the person tested negative or positive for COVID. Whether or not they actually had a COVID test at all.
Observing home from the hallway through an open door and using technology to supplement the assessment if a client is unwilling to let an APS caseworker in  gives us an opportunity to at least meet faceto-face…Not too many clients are keen on doing assessments over the phone,…but they have cooperated.

Proactively reaching out to clients and collateral reporters
Proactive outreach to all clients to identify emergencies and provide support, reduce isolation strategies were in five thematic categories: making in-person assessments as safe as possible (4 strategies), increasing collaboration with other community-based programs and service providers (3), reducing in-person assessments and prioritizing which clients receive them (3), proactively reaching out to clients and collateral reporters (2), and facilitating remote court hearings through technology and inperson facilitation (1).
Client Assessment. To make in-person assessments as safe as possible, APS added pre-screening questions at intake before a home visit to assess COVID-19 risk/exposure. During the visit, a worker might observe the home from the hallway through an open door and use technology to supplement the assessment if a client was unwilling to let them in. Also, they would make in-person face-to-face visits as short as possible to minimize exposure, focusing on observations, while gathering other needed information via telephone. Caseworker #1: We're trying to do a five-minute assessment, and…this person is coughing, is not wearing a mask, so you…close the door…and…talk to them from the hallway on the phone.
Caseworkers also offered clients masks and hand sanitizer to increase safety and build trust when conducting home visits.
Several strategies were employed to increase collaboration with other community-based programs and service providers as well. This collaboration involved sharing information and clinical impressions as well as performing joint visits. In some cases, APS used client's interactions with other programs to build trust with a client reticent to engage with them.
Caseworker #8: When we're not able to actually get through the door [during an assessment], what I found myself doing is I really have to figure out who's involved with this household, if anyone….Is there a home care agency? Is there…Meals on Wheels? Has there been any police interaction?…When I am able to speak to [other agencies/programs] and I get any bit of information, I can show up to the home again and say, "We saw that you asked for help on such date. You know I want to talk to you a little bit more about that…I want to see what I can assist you with. You know did you get the help that you were looking for at the time?" And then that kind of gives me a little bit of a foot in the door.
APS also reported relying during the initial surge on other service providers to confirm the health and safety of a client or referred person.
Multiple reported strategies involved reducing in-person assessments and prioritizing which clients receive them. These included: (1) taking advantage of a New York state policy implemented during the initial surge relaxing requirements around timeframes for in-person client assessment, (2) prioritizing cases with potential elder mistreatment for in-person investigation, and (3) conducting assessments remotely via tele-technology for clients that refuse in-person evaluation and for clients without emergent issues.
Two reported strategies involved proactively reaching out to clients and collateral reporters. APS reported attempts to proactively reach out to all clients to identify emergencies as well as provide support and reduce isolation. They also increased outreach to collateral reporters including, family, friends, and neighbors for information about a client, to build rapport during a visit/assessment, and even to perform informal wellness checks. Allowing for Remote Work/Supporting Staff. Strategies to facilitate remote work and support staff were reported by APS leadership (13 strategies), supervisors (3), and caseworkers (1) (shown with representative quotations in Table 3). APS leadership facilitated remote work by providing devices and modifying processes with partners to replace paper mail with electronic communication/processing. APS leadership supported staff by ensuring that all had access to PPE. Leadership also encouraged vaccination by offering priority access and

Strategy
Representative Quotation(s)

Transition to remote work
Providing devices to ensure the ability for all APS staff to work remotely Leader #4: The powers that be decided, "Let's get every worker access to remote," whether it's through a device of their own or a device that the city will get you…Every worker has a city-issued laptop and or I-pad where you can get your emails, you can get all your remote databases, your APSnet [the APS case management system], your time sheets and stuff.
Modifying APS processes and relationships with vendors, banks, government agencies to replace paper, mail with electronic communication/bill payment Leader #5: I reached out to that utility vendors…to get them to agree to send them digital bills rather than the mail. So I reduced a number of mail coming into the office and the need to have someone in the office to go through the mail.

To support staff
Ensuring that APS workers visiting clients have access to personal protective equipment Leader #4: APS had secured and continues to secure PPE for the workers. Gloves, masks, hand sanitizers, coveralls…to make them feel as comfortable as they can while they're visiting the clients.
Encouraging vaccination for staff, including offering priority access and time off from work to obtain make sure that we're never more than five, ten minutes away from an email response because what may seem five minutes to us may seem like a lifetime to a worker…If a worker sends you an email, please try to respond as soon as possible even if you don't have an answer let them know that you're out there.
Personal outreach from senior leadership to APS staff Leader #3: When your head of your administration, your Deputy Commissioner, picks up the phone to see how you're doing and what resources we can provide,…that's an amazing thing.
(continued) time off from work. They also held regular staff meetings, offered mental health resources, encouraged staff to take leave whenever necessary, and even had APS social workers check in with staff individually on well-being.
Leader #3: We did…social work outreach during COVID because… although we take care of the clients, we…forget about ourselves…We were able to find out what was going on with each worker. What was really special about this, between the directors and the deputies, [is that] they were able to pinpoint what was going on with their workers. Sometimes…the clients were not the only ones who felt lonely.
Leadership also increased staff access, encouraging contact via cell phone and email and reaching out personally to APS staff members to support them.
Leader #4: Myself and my deputies…are al-ways…available. The staff have our cell phone num-bers….Between myself and my two deputies, [we] make sure that we're never more than five, ten minutes away from an email response because what may seem five minutes to us may seem like a lifetime to a worker…If a worker sends you an email, please try to respond as soon as possible even if you don't have an answer let them know that you're out there.
Leadership formally recognized excellent staff member performance and sent daily inspirational e-mails.
APS supervisors arranged for workers to cover for each other and divide tasks including field visits and focused on closely supporting caseworkers. They even accompanied staff on home visits to demonstrate recognition of risks/ willingness to assume them.
Supervisor #10: I helped a social worker who was a little overwhelmed. … I would go out with her on certain cases…when she felt unsure because,…if she has to go out, I have to show her I'm willing to do the same thing. as a supervisor…[to show] she has my back.
APS workers themselves reported supporting each other by sharing tasks. Sending daily inspirational e-mails Leader #6: I used to send emails to the staff every morning…They were just words of inspiration.

Strategies from APS supervisor
Arranging for workers to cover for each other, divide tasks and balance field visits with other responsibilities Supervisor #14: I'll have the other…staff in the unit go out and make their visits for them…In turn, the staff that's home can make the field visits…or come to the office. I'll have them assist those workers by doing other things, helping them out, making phone calls also for those other workers.
Focusing on closely supporting caseworkers Caseworker #6: She's always there… She's always there at any moment to answer calls and text and to provide documents and general direction and uh just cues on what to do and where to go.
Accompanying staff on home visits to demonstrate recognition of risks and willingness to assume themselves Supervisor #10: I helped a social worker who was a little overwhelmed. … I would go out with her on certain cases…when she felt unsure because,…if she has to go out, I have to show her I'm willing to do the same thing. as a supervisor…[to show] she has my back.

Strategies from APS caseworkers
Supporting each other by sharing tasks Caseworker #4: You know like, coworkers' colleagues, the great people that know me, they'll check in. They, they always help out. Supervisor #12: In the beginning of the pandemic, there was an issue with food… I've had caseworkers that had to wait on food pantry lines for them…Sometimes that worker needed to go to the next visit and then I would have to dispatch someone else to go out and do the food pantry pickup.
Caseworker #4: You know like, coworkers' colleagues, the great people that know me, they'll check in. They, they always help out.
Supervisor #12: In the beginning of the pandemic, there was an issue with food… I've had caseworkers that had to wait on food pantry lines for them…Sometimes that worker needed to go to the next visit and then I would have to dispatch someone else to go out and do the food pantry pickup.
In describing challenges and strategies, caseworkers, supervisors, and leadership each had differing perspectives based on their role and responsibilities. Caseworkers were primarily focused on how to safely continue to do their work, which involved visiting homes and exposing themselves and clients to COVID. Supervisors, many of whom had recently been caseworkers, were focused on balancing ensuring that the client work was completed and that the caseworkers felt safe and supported. Leadership was trying to advocate for and support their frontline caseworkers and supervisors and transform the APS program so that it could continue to provide vital assessments and services to vulnerable adults during the surge.

Discussion
Our work is the first, to our knowledge, to explore the experience of different types of APS workers in providing services to vulnerable adults during the COVID pandemic. Through qualitative methodology and the inclusion of supervisors and caseworkers in addition to leadership, we were able to improve understanding of challenges and strategies during this unprecedented and uncertain time. We focused on New York City, which was more deeply impacted than most other US communities with a particularly intense initial COVID surge. COVID overwhelmed New York before the disease, and how to effectively treat or prevent it, was well-understood. The city was locked down, adequate PPE was not available, and there were no vaccines. Therefore, an in-depth exploration of APS challenges and strategies in this hard-hit community is particularly valuable when considering response strategies to future pandemics or other societal disruptions.
APS experienced many of the same challenges as other frontline workers, with many strategies developed also applicable more broadly. Notably, though, APS occupies a unique position in most communities as the only program that performs investigations and regular home visits on vulnerable older and disabled adults. Early in the pandemic, frontline APS caseworkers continued to perform home visits even though adequate personal protective equipment was not initially available.
Our findings support and expand on existing reports, including a recent national study with a survey of state administrators and interviews with APS staff (Teaster & Kebede, 2020). In the national survey, most state administrators (81%) reported receiving fewer client referrals, even though a majority (52%) reported believing that client need had increased. In our study, APS reported believing that isolation and stress from the pandemic surge likely increased particularly financial exploitation and physical abuse. In the national survey, nearly half (46%) of state administrators indicated that clients were less willing to engage with APS. We found that this reticence was potentially due to both concern for COVID exposure as well fear that APS might separate them from a caregiver on whom they depended. This underlines the importance of the formal and informal strategies described here to increase client engagement.
Similar to our findings, the vast majority of states reported that staff was concerned about being infected during face-toface investigations (89%) and about infecting clients (80%) (Teaster & Kebede, 2020). This demonstrates that, in addition to providing PPE, the strategies NYC APS developed and implemented to protect staff and clients, including adding COVID pre-screening questions at intake, minimizing the length of in-person assessments, conducting assessments remotely via tele-technology, and offering masks and hand sanitizer to clients, were important and may be useful for other APS programs to consider.
Our work found that APS was burdened during the pandemic with assessing referrals submitted by other service providers that reported they were unable to make home visits and their clients needed to be checked on, not necessarily because the adult met APS eligibility criteria. Other states also reported taking on additional roles and responsibilities during COVID-19, with 69% assisting other organizations (Teaster & Kebede, 2020). Given that home visits are critical to ensure safety for isolated vulnerable adults (Liu & Delagrammatikas, 2021), particularly those who may not have access to or be comfortable using technology, APS may anticipate and plan for a similarly expanded role in future crises.
Most states reported continued collaboration with critical APS partners including law enforcement (41%), food banks (39%), and other service providers (Teaster & Kebede, 2020). APS in NYC reported expanded close collaboration, including sharing information and conducting joint visits. Ideally, the collaboration strategies developed and strengthened during COVID-19 will be retained in the long term.
Incorporating new technologies into work processes was challenging for APS, as the pandemic surge highlighted how behind the program was in adopting technology for staff. By exposing this, the COVID surge accelerated technology adoption. Using technology was a key component of several APS strategies to improve client assessment and coordinate with staff. In addition to facilitating remote assessments and remote work, technology was incorporated/used in nontraditional ways, including connecting clients to judges for court hearings.
NYC APS proactively reached out to clients to check in and identify unmet needs during this unprecedented time. Other APS programs have reported taking a similar approach. During the first COVID-19 surge, San Francisco APS also decided to contact all clients who had at least one confirmed/ inconclusive substantiation of elder mistreatment type in 2020, were above the age of 80, or lived alone (Liu et al., 2021). This contact identified that a quarter of these clients had at least one unmet medical or other service need, underscoring the potential value of this proactive approach.
The national survey showed that some states in addition to New York relaxed or eliminated timelines, but most did not (Teaster & Kebede, 2020). Our research suggests that doing so increases the ability of APS staff to do their work effectively while protecting clients and themselves. Additionally, this facilitates the prioritization of the highestrisk vulnerable adults. In NYC, potential victims of abuse were prioritized. Though existing statutory timelines exist to ensure that vulnerable adults are evaluated promptly and regularly, easing or eliminating them in a crisis coupled with a prioritization strategy may be considered more broadly.
Our research highlighted the challenges associated with performing services that rely on home visits and paper/mail. NYC used technology and flexibility to overcome these challenges, including working with vendors, banks, and government agencies to change processes. All APS programs, particularly given the financial responsibilities they take on for clients, should consider their level of dependence on paper/mail and minimize this in anticipation of similar disruptions in the future.
Similar to NYC, other APS programs recognized the importance of supporting staff of a frontline organization during this unprecedented time. Most (77%) of APS staff had increased communications/check-ins with their supervisors (Teaster & Kebede, 2020). More than half (62%) increased opportunities for peer discussion and peer support, and 51% were provided access to mental health resources (Teaster & Kebede, 2020). That NYC APS leadership developed a broad range of 13 strategies to support staff shows how focused they were on addressing this issue and offers ideas for APS leadership in other communities. Supervisors and caseworkers themselves developing strategies emphasizes that everyone in the organization can contribute to supporting each other.
Notably, many of the strategies adopted by APS, such as enhanced collaboration and cooperation with other programs, represent improvements in good general practice broadly applicable beyond the COVID pandemic. The disruption from the initial surge may have served as a catalyst, accelerating changes that were already recognized as potentially helpful. Future research is needed to explore whether these remain in place after APS operations return to normal.
An investigation of Child Protective Services (CPS) workers' experiences during COVID found similar challenges and strategies (Renov et al., 2022). Many CPS services were adapted to be delivered virtually. CPS workers encountered barriers to remote work and obtaining PPE. CPS developed innovative strategies similar to APS including expanding collaboration with other communitybased agencies and proactively reaching out to families. Contrary to our findings with APS, CPS workers reported not making changes to investigation guidelines or timelines during the pandemic. That APS needed to do so may be due in part to lower levels of resources for APS than CPS in many areas. Also, CPS workers reported substantial burnout and compassion fatigue, which we did not find among APS workers in NYC. This may be due to the extraordinary efforts of APS leadership and supervisors to support workers. Alternatively, APS workers with these experiences may have chosen not to participate in our research.

Limitations
This study has several limitations. Our work is based on reports from APS in a single northeastern US city, which was impacted greatly by the initial COVID-19 surge in Spring 2020. Our findings may not be generalizable. NYC APS has a larger budget and staff than many other APS programs, and APS in different counties and different states varies substantially. Programs in different geographic regions, with less resources, and different timing of COVID case surges may have faced very different challenges addressing abuse during the pandemic. Further, the strategies used to combat these barriers may have varied. Our goal, however, was to highlight the innovative practices APS developed, in a short period of time, to address the unique issues COVID-19 presented. We hope some of these practices might be translatable to other communities. Also, that even a well-funded, highly functioning urban APS agency faced such profound challenges may serve as an important reminder that agencies with fewer resources are even more vulnerable and should consider developing strategies proactively in anticipation of a future pandemic or other societal disruption.
For logistical reasons, we did not conduct focus groups or interviews until nearly 1 year after the initial surge started. We needed to secure approval from various NYC agencies to conduct the research. When this research was conducted, vaccines had become widely available and, while COVID-19 remained a large concern for many, lockdowns had ended, and many but not all community-based service providers had returned to conducting home visits. Participants' responses focused on experiences during the initial surge, and their recollections may have been biased, given the change in circumstances. Since this research was conducted, though COVID-19 has persisted, circumstances have further evolved, as have APS services. Future studies should examine this evolution, including, for example, the impact of vaccine hesitancy and resistance to wearing masks, and its impact on APS in New York City and elsewhere.
We used video-based online conferencing to conduct this research. While this approach has limitations and disadvantages that may have influenced our results (Lobe et al., 2022), we chose it so that participants were not limited to those who were willing and able to meet in person in a specific location and because it reduced the burden of participation. Another limitation is that participation in focus groups and interviews was voluntary, which could create potential for selection bias, with participant views differing significantly from those of non-participants. Though we recognize the potential value of inviting respondents to provide feedback on the findings, as demonstrated in recent APS research (Steinman & Anetzberger, 2022), we opted not to pursue this to avoid overburdening busy APS workers who were volunteering their time to this project. Finally, though thematic analysis is recognized as an appropriate research technique, themes and their categorization may be affected by the subjective manner in which the transcripts were reviewed by the research team. We hope that the broad range of perspectives of the research team minimized this. Despite these limitations, we believe that this study offers valuable insights into how APS in NYC adapted to successfully serve and protect victims of elder mistreatment during this unprecedented time. Some of these strategies may be easily employed by other APS programs in other communities.

Conclusion
APS has played a critical role in serving vulnerable adults, including victims of abuse, during the COVID-19 pandemic. APS continued to conduct investigations and implement services while maintaining safety for themselves and clients. As one of the only community-based programs performing home visits and interacting with vulnerable adults in-person during the pandemic, their role in protecting these adults actually increased, with other programs dependent on them. Leadership, supervisors, and individual APS workers were able to overcome challenges through resilience using a variety of innovative formal and informal strategies. We hope that these findings will serve as a useful case study for other communities and future large-scale societal disruptions. These findings and the experience of APS during Covid-19 may also be of value to local municipalities and help inform emergency response plans. As the pandemic continues to impact communities in new ways, with appearance of variants, availability of and hesitancy about vaccines and boosters, we plan to conduct follow-up to understand evolving APS response.