En español | When Denise Goodwin was hired to do housework and other chores in the San Diego home of Carolyn and Gerald Rabourn, she was welcomed with open arms. Carolyn, 91, in the final stages of lung cancer, was receiving home hospice care, and Gerald, 88, a lifelong tennis and health buff, was worn out from the daily grind of supporting and aiding his wife.
"He thought she was just wonderful," Bill Mitchell, deputy district attorney in San Diego, says of Gerald Rabourn's feelings for Goodwin. "He pretty much saw her as his angel."
But after Carolyn died, Goodwin didn't just clean house; she started cleaning up. First, she absconded with nearly $600,000 in assets, including the title to the Rabourn home. Once the money was gone, Gerald Rabourn disappeared, too, under mysterious circumstances. Arrested in 2011, Goodwin was preparing to leave for a Mediterranean cruise; she was later charged with Gerald Rabourn's murder.
Every day, in millions of homes across the country, legions of home health aides are helping to meet the basic needs of America's older adults — cooking, cleaning and assisting with activities of daily living. Nearly 10 million adults age 65 and older receive care at home or in residential care settings other than nursing homes. That number is projected to skyrocket as the 65-plus population rises from 40 million today to more than 70 million in 2030, according to U.S. Census Bureau figures.
While many home health aides are stellar, others, like Goodwin, could be your worst nightmare. Financial, physical and emotional abuse is on the rise, if the number of arrest warrants and abuse complaints is any indication. Research suggests that 1 in 10 Americans 60 and over have experienced some form of elder abuse. But even as prosecutors around the country target elder abuse, many cases go unreported. Some older adults fear that if they complain, they will end up in a nursing home. Those with dementia may not be able to remember that they have been abused: Studies show that more than a third of people with dementia suffer psychological or physical abuse at the hands of people providing care. Meanwhile, their natural advocates and watchdogs — family members — often live hundreds or thousands of miles away.
Consider the case of Ruthann Jacox, a Tucson, Ariz., woman with multiple sclerosis whose only sibling lived in Pennsylvania. Never married, Jacox had hired an aide to provide care, who subsequently rationed her food and water so she wouldn't have to take her to the bathroom. Only after Jacox was hospitalized with bedsores down to the bone was the abuse ever reported to adult protective services. Jacox — a retired nurse — later died. Her aide got two years in jail.
An unregulated industry
Laura Mosqueda, M.D., is co-director of the National Center on Elder Abuse, a federally funded initiative that serves as a coordinating body and clearinghouse for research and training on elder abuse, neglect and exploitation. She points to the intersection of a growing elderly population with a burgeoning, virtually unregulated industry of home health care workers as the real culprit.
For starters, there are no federal regulations covering home-care workers, other than broad standards for care provided under Medicaid. Only about half of all states require home-care agencies to conduct any sort of training for their employees. Just 15 states require agencies to conduct periodic in-home reviews to make sure workers are doing their jobs. Most states require criminal background checks of home-care workers but do not require agencies to check records in other states.
One 2012 study published in the Journal of the American Geriatrics Society found that less than a third of home-care agencies screened their employees for illegal drug use, and just 16 percent tested for basic knowledge about providing care in the home. "The people who work [in homes] try their best, but the problem is they are not always supported by the agencies that hire them," says study coauthor Lee Lindquist, M.D., chief of geriatrics at the Northwestern University Feinberg School of Medicine. "The agencies will charge $50 or more an hour, but keep a lot of the profit for themselves rather than investing it in education, training and supervision."
Personal care aides and home-health aides are the nation's second- and third-fastest growing occupations, according to the U.S. Bureau of Labor Statistics. That has not led to higher pay or benefits for workers.
One in 4 home-care workers live in households below the federal poverty line, and a third lack health insurance, according to the Paraprofessional Healthcare Institute, a Bronx, N.Y.-based research and advocacy group. Long hours and low pay — the median wage is $9.61 an hour — contribute to high turnover and inconsistent care.
The role of the family
While they have their own troubling history of abuse, families remain the bedrock of home care to ailing seniors. AARP estimated in 2009 that more than 42 million family members provide care to an older adult. But there is also a growing care gap, as boomers transition from giving care to needing care themselves. Even among the most devoted families, strains are already developing.
The children of 99-year-old Peter Mazza exhausted the inheritance from their father's estate on private home care before turning to the New York Medicaid program. Family members continued to make daily visits to check on him, and even installed video cameras in his Staten Island home. They ended up with a horror show: A video from last April shows their father falling and breaking three ribs while reaching for his walker to go to the bathroom as his home aide watches impassively. Mazza was hospitalized and died two months later in a nursing home. The family has filed suit in the state Supreme Court in Manhattan.
"We were not a family that was not involved. That is the scary thing," says Carol Ann Mazza, who lived 10 minutes away from her father and who checked the video online over coffee as part of her morning routine. "We were involved and we were there every single day. Other than living there, there is nothing more we could have done."
A call for solutions
Across the country, lawmakers are starting to recognize the need to ensure better care for homebound seniors.
With money from the Affordable Care Act (ACA), six states, including Michigan and California, are working to develop more rigorous standards for training and assessing home-care workers. And several nonprofit groups have created registries to match the needs of seniors living at home with aides who have specialized skills, such as working with people with dementia or Alzheimer's.
The Elder Justice Act, which Congress approved as part of the ACA, called for spending $500 million to help state and local adult-protective services better detect and prevent elder abuse. But lawmakers have yet to authorize any money for the program. That lack of funding has also stalled plans to conduct a comprehensive study of elder abuse.
In what labor groups saw as a major step toward improving the lot of workers and their patients, the Obama administration approved regulations in 2013 that would require home-care agencies to start paying overtime to their employees, reversing a decades-old exemption under federal law. But the home-care industry filed suit, and a federal judge in Washington struck down the new rules, which were scheduled to go into effect Jan. 1, ruling that the Labor Department had exceeded its authority.
Phil Bongiorno, executive director of the Home Care Association of America, a trade group that represents 2,500 home-care businesses with some 300,000 employees, says the industry was concerned that the requirement to pay overtime would make care less affordable as higher costs were passed on to consumers. He adds that the trade group has developed "best practices" for training and screening employees, although they are not currently a condition of membership in the organization. "We are trying to set the standard in home care," Bongiorno says.
'She was like a sociopath'
Denise Goodwin, 47, had worked as an assistant in an animal hospital before seeing the profit potential in working with humans. Prosecutors say she preyed on older men, trolling online senior dating services to find victims. She applied at a San Diego home-care agency, specifically requesting hospice duty. After she passed a background check, the agency assigned her to the Rabourn home in 2010.
In short order, Goodwin plundered the estate, charming Gerald Rabourn into giving her control over his finances after his wife died. She sold the house and liquidated his stocks, pouring the money into condos. A suspicious neighbor called adult protective services, but the agency closed an investigation after Rabourn refused to cooperate.
Based on phone and bank records, police believe Goodwin murdered Rabourn a month after arriving on the scene, although his body has never been found. She covered her tracks for several months by telling people that Rabourn had remarried and was on vacation. Mary Weaver, Rabourn's daughter, who lived in Kansas City, filed a missing-persons report with San Diego authorities in February 2011 after her birthday passed without a card from her father, a missed ritual that to her was a telltale sign that something was profoundly wrong.
Goodwin was convicted of murder by a San Diego County jury last October. She was sentenced Jan. 30 to life imprisonment without parole. Weaver, a chaplain who ministers to people at assisted living facilities, attended the sentencing and used the occasion to eulogize her father. Weaver was hoping that Goodwin would reveal the location of her father's body so he could be laid to rest, but instead, Goodwin sat emotionless in the courtroom. "She was like a sociopath," Weaver says. "Most people should understand, when you are putting someone in your home, you need to be sure this is who they say they are."
Illustration by Jesse Lenz
What to look out for and where to go for help
AARP is working on several fronts to help families avoid unwittingly hiring an unqualified aide to help their older loved ones.
"Abuse of older Americans is unconscionable, especially when the crimes are perpetrated by those we count on to care for our loved ones," said Nancy LeaMond, an AARP executive vice president.
"Family members provide the bulk of care to help their older parents, spouses and other loved ones live independently at home, where they want to be," LeaMond said. "Sometimes people need to turn to home health aides for assistance. We have an obligation to ensure those people don't take advantage of the loved one."
AARP staff and volunteers work with state legislatures to:
- Preserve and strengthen state adult protective services agencies
Those agencies investigate complaints about abuse, neglect and exploitation of adults who are unable to care for themselves or make decisions due to mental or physical impairment, illness or a crisis in their lives.
In 2014, AARP helped increase or ward off efforts to cut funding for the agencies in five states: Arizona, Ohio, Oregon, Utah and Wyoming.
- Adopt legislation to help prevent, detect or report and address financial exploitation of older people
Last year seven states (Florida, Kansas, Massachusetts, New Hampshire, Oregon, Rhode Island and Virginia) enacted bills to do that.
- Increase criminal and civil penalties against perpetrators of financial exploitation or amend the definition of "elder abuse" to include financial exploitation
Lawmakers in Iowa and West Virginia last year adopted legislation that addresses financial exploitation in this way.
For more on AARP's work to protect vulnerable older people, visit aarp.org/supportcaregivers. The site includes online resources for family caregivers.
People who witness abuse should call 911. A state-by-state list of places to report abuse is at the U.S. Administration on Aging's National Center on Elder Abuse website.
Rick Schmitt, a former law and justice correspondent for the Los Angeles Times and the Wall Street Journal, profiled the Medicare Fraud Strike Force in the November 2014 Bulletin.
10 Questions to Ask Before Hiring a Health Aide
No one with a need for a home health aide should be afraid to seek necessary care. But how do you ensure that your loved one is in safe hands? Lee Lindquist, M.D., chief of geriatrics at the Northwestern University Feinberg School of Medicine, offers these 10 questions to ask when vetting home-care agencies.
1. How do you recruit home health aides, and what are your hiring requirements?
2. Do you do criminal background checks on prospective aides? How about drug screening?
3. Are health aides certified in CPR, or do they have any health-related training?
4. Are the aides insured and bonded through your agency?
5. What competencies are expected of the aide? Lifting and transfers? Personal care skills (bathing, dressing, toileting)? Training in behavioral management, cognitive support?
6. How do you assess what the aide is capable of doing?
7. What is your policy on providing a substitute home health-care aide in the event a regular care provider cannot perform the services in your contract?
8. If there is dissatisfaction with a particular home-care provider, can he or she be replaced "without cause"?
9. Does the agency provide a supervisor who is responsible for regularly evaluating the quality of home care?
10. Does supervision occur over the telephone, through progress reports or in person at the home of the older adult?
AARP's Caregiving Resource Center offers information on hiring home health aides as well as a tool to help find providers in your area.