AARP Looks at Criminal Background Checks for Home Care Workers

Publicly funded programs like In-Home Support Services (IHSS) that provide helpers to assist with such basic daily tasks as eating, bathing, housekeeping, and shopping, are a godsend to people with disabilities who want to live independently. Some of these programs reimburse families for providing care to their own members, buffering them against impoverishment. But the lack of screening and oversight of caregivers, and the unchecked access they have to society’s most vulnerable, have also made caregiving an attractive job choice for opportunists and predators. In some families, the job falls to troubled or dysfunctional members who can’t find other work. As a result, shocking accounts of abuse and neglect by publicly paid workers are hitting the press almost daily. These accounts are even more shocking when it’s revealed that an offender was recently released from prison or is on the lam.

In response, states have enacted criminal background checks. But while there’s general agreement that checks are needed, developing systems isn’t easy, as AARP's excellent new report Developing Effective Criminal Background Checks and Other Screening Policies for Home Care Workers shows. The report raises such complex questions as what crimes should disqualify workers, do we apply the same standards when helpers are family members, how do we ensure fairness, who pays, and how will checks affect an already inadequate supply of workers?

A Survey of State Laws
Although much of the funding for in-home care comes from the federal government, the feds defer to states to develop programs and policies for hiring and screening workers. AARP commissioned the National Conference of State Legislatures to conduct a state-by-state comparison, which revealed widespread variations.

“We were surprised at the wide diversity of provisions on which crimes disqualify job applicants,” says Naomi Karp, Policy Advisor for AARP’s Public Policy Institute, which produced the report. “Some states (including California) only disqualify applicants for past offenses against vulnerable people, while others exclude them for a simple DUI.”

Of the 46 states that mandate pre-employment criminal background checks, most disqualify applicants who’ve been convicted of homicides and other violent or sex-related offenses. Some include fraud-related crimes and crimes against vulnerable adults and elders. The laws also vary in terms of which workers are covered. Some, for example, require background checks for family members who receive payment for providing care while others exempt them.

To Work or Not to Work: A Measured Approach
Criminologists, offenders’ rights advocates, and common sense tell us that mitigating factors need to be considered before disqualifying applicants with criminal histories, including their age, the length of time since they committed the crimes, their work histories subsequent to offending, and whether or not they can show they’ve been rehabilitated. Naomi adds,

“Our study identified exciting criminology research on redemption —determining when a person with a criminal history no longer poses a greater risk of committing a crime than anyone else. Professionals in the elder abuse and long-term care fields are unlikely to be aware of this, never mind policymakers.”

She further cautions against over regulation.

"Although we need to find ways to protect home care consumers, we also need to avoid unnecessary disqualifications as workforce demand increases and to increase fairness to job applicants.”

The report suggests for example that when elders use public funds to hire their own family members to provide their care, the standards should be relaxed. It also acknowledges that in the interest of consumer choice and empowerment, some consumers of home care should be given the opportunity to assume greater risk (as long as they’re capable of understanding those risks).

Let Research Be Our Guide
While researching an article on this topic several years ago, I interviewed criminologist Vernon Quinsey who explained that the point where the risk of re-offending becomes negligible is different for different crimes and different settings. To understand the risk that home care workers with criminal histories will re-offend requires that we study home care workers with histories who re-offend. In other words, our field’s tendency to borrow knowledge from other fields won’t work here. We need our own research.

Other Approaches
The report further cautions against over relying on background checks and highlights the importance of detailed application forms with disclosure requirements, thorough interviews, reference checks, drug and alcohol screening, credit histories, and training. Other recommendations include “rap-back systems,” which refers to programs that automatically flag new disqualifying crimes committed by workers after they’ve been hired and alert employers. It calls for a tiered system that begins with low cost checks of state records and registries for all applicants, followed by more extensive checks when the initial checks suggest problems. Screening systems also need to provide for appeals and waivers, or “rehabilitation reviews” to let disqualified applicants demonstrate their suitability.

Surprisingly, background checks may have a powerful deterrent effect. The report cites the findings of a Centers for Medicare & Medicaid Services (CMS) study that shows that while fewer than 4% of applicants in state criminal background check pilot projects were disqualified by checks, close to 19% withdrew their applications before the checks were made.

Next Steps
While AARP has made an enormous first step in tackling this complex issue, many more questions still remain, including:

• How do we decide when elders with cognitive impairments are capable of making hiring decisions? In doing so, we need to acknowledge that hiring is just the first step in a process and anticipate what will happen down the line. Once they hire workers, for example, will impaired elders be able to detect financial abuse, withstand manipulation and intimidation, or even ask for help?

• Will criminal background checks disproportionately affect communities that are overrepresented in the criminal justice system?

• Will policies that give elderly consumers greater responsibility for vetting their own workers carry with them greater liabilities (e.g. for hiring workers who are undocumented)?

The AARP report hasn’t generated as much media attention as expected, which isn’t surprising to me. Accounts of recently released sex offenders getting jobs as home care workers makes for better copy. But the painstaking, thoughtful approach that AARP has taken in this report is invaluable to those who are working on policy. Thanks, AARP!

For copies of the report, see Developing Effective Criminal Background Checks and Other Screening Policies for Home Care Workers

For more on abuse by caregivers and additional resources, visit my Web site at: http://lisanerenberg.com/learn/caregivers.html

In Memory of Gita Shah

Last week, my good friend Gita Shah of Mumbai passed away. Although I’d known she’d been sick for some time, it still came as a shock. She was one of those forces of nature that seem indestructible. My sadness though has been tempered by a flood of joyful memories.

I met Gita in Mumbai in 1992 during a Council for International Fellowship (CIF) exchange program for social workers from around the world. Gita, an instructor at the Tata Institute of Social Sciences, was on the committee that introduced us to India’s history, economy, politics, culture, and social services. It was also an opportunity to reflect on our own countries’ approaches to social work and social justice. I was instantly drawn to Gita’s exuberance, intelligence, and gentle grace.

After the orientation, I went to Pune for my fieldwork assignments at an AIDs prevention program and a village social development program. I also got to tag along with a class of students from the Karve School of Social work on a tour of rural development projects led by instructor Anjali Madeo. It was a revelatory experience. We visited women’s craft collectives that were demonstrating that getting money into the hands of women had a more profound impact than medical facilities on health. And we learned that women’s literacy programs were more successful than contraception in curbing population growth. I’ve been thinking about these experiences a lot lately as the field of elder abuse goes global, with groups like the Older Women’s League and WITNESS addressing abuse from a human rights perspective and highlighting the role of women.

By the time we got back to Mumbai for the CIF wrap-up, I didn’t want to go home. Fortunately, Gita had taken an interest in my work and invited me to stay on. She got me an invitation to one of the first-ever Indian conferences on aging and arranged for me to give a talk on aging in America to a group of her colleagues. After she’d assured me that moving into her home wouldn’t be any trouble, I agreed, later discovering her son and daughter-in-law sleeping on the living room floor. Over chai at her kitchen table, she bemoaned the disintegration of the joint (extended) family in India as her husband, Chandra, their sons, daughters-in-law, and mother-in-law streamed past. We dreamed up collaborations.

A year or two later, she visited me in San Francisco, where I showed off our giant redwoods and arranged for her to give a talk to a group of American Society on Aging members. She cooked an Indian meal for my friends and taught us Indian dances. In the next few years, she explored elder abuse in India and co-authored an article for the Journal of Elder Abuse & Neglect (volume l6, issue 3/4, 1995).

Once, during the CIF program, a member of the planning committee confided that she’d only agreed to serve because “I can’t say no to Gita.” I came to know what she meant. It wasn’t that Gita badgered or pressed. It’s just that her passion was contagious, and anything she was involved in seemed worth doing—something you wanted to be a part of. When she spearheaded a program for the elderly at the Family Welfare Agency (FWA), I sent checks and tracked down the resources she requested. Two summers ago, when CIF held its international conference in Cleveland, Gita prepared a paper but had to cancel when she didn’t get the funding she’d been counting on. When she asked me to fill in, I wasted no time convincing my husband, Dan, that Cleveland would be the perfect starting point for the midwestern back-to-our-roots vacation we’d been talking about for years. Another Indian colleague eventually came forward and offered to give the paper, but we headed east anyway and had a wonderful time.

Over the years, Gita and I wrote often. She reported on her travels to Kenya to train trainers, and her work with Project SHARE, which focuses on rainwater harvesting in rural areas. She introduced me to her niece Alpa Desai, also a social worker at FWA, who lived for a while in the Bay Area and shares Gita’s interests, commitment, and charm.

Just a few weeks ago, Gita invited me to give a talk in India, and I can’t seem to shake the feeling that I’ve left a task undone, a commitment unmet. It’s a good feeling really, this fleeting summons from my old friend. I will miss her enormously.

Financial Elder Abuse: Hot Off the Presses

I’ve worked with Pam Teaster, Professor at Virginia Polytechnic Institute and State University, and president of the National Committee for the Prevention of Elder Abuse (NCPEA), on a couple of research projects over the years and have always been impressed by her readiness to design studies that answer questions practitioners most want the answers to. It’s not easy to translate practice wisdom or professionals’ hunches into conceptual frameworks and designs that pass scientific muster. Which is why practice-based studies often end up employing such dubious sounding methods as “convenience” and “snowball” samples. Still, they yield insights that are enormously helpful to the field.

Pam’s recently released study on financial exploitation breaks new ground methods-wise and sheds light on how financial abuse is being addressed by the media around the country. Broken Trust: Elders, Family and Finances was a collaboration of NCPEA, Virginia Polytech, and the MetLife Mature Market Institute, the research branch of the insurance company. Pam and her colleague Karen Roberto analyzed financial abuse cases identified through the electronic clipping service operated by the National Association of Adult Protective Services for the Administration on Aging’s National Center on Elder Abuse. The service draws from Google and Yahoo scans of billions of Web pages a day. The search yielded 266 articles on financial abuse that were posted between April and June of 2008. From these, they collected information about victims and perpetrators, their relationships, victims’ losses, and case outcomes. They also reviewed the academic and trade literature on financial abuse and listed promising practices drawn from a database run by NCEA.

I was a little surprised to see “Medicare/Medicaid fraud” among the forms of abuse that were included since the term typically refers to situations where it’s the “system” that’s ripped off, not program beneficiaries. Like many in the field, I worry about defining elder abuse so broadly that the term becomes meaningless, and I’m always on the lookout for types of abuse that we can exclude. But the example cited in the report, of a physician who performed unnecessary surgeries on 865 elders and charged Medicare or Medicaid over $11 million for them, was certainly compelling. Although it might be argued that it was the system that suffered the financial loss, there’s no denying the trauma and suffering that the patients must have endured. Professionals and courts alike are struggling with the question of whether or not physical abuse, neglect, or other mistreatment, when committed for profit, also constitutes financial abuse. Other forms of financial abuse mentioned in the study include telemarketing fraud, repair and contracting scams, "sweetheart scams," fraudulent advice from insurance salespeople and stockbrokers, abuse of powers of attorney and guardianship, identity theft, and Internet "phishing."

Among the findings that are already being widely cited is the estimate that elder financial abuse costs older Americans at least $2.6 billion a year. The figure was derived by annualizing the total losses reported during the 3-month study period ($400 million) and assuming that the losses in the 40% of cases where no dollar figure was provided were comparable. I found it interesting that the largest single category of abusers was trusted professionals, which includes attorneys and fiduciaries, who accounted for 18% of the cases. They were followed respectively by family members (17%), non-agency caregivers (11%), and agency caregivers (9%). Also of interest was that almost 2/3 of the victims (65%) were women.

I asked Pam what, if anything, she found surprising. She cited the severity and impact of the abuse. “One victim likened the exploitation to being raped. I can easily see it. It would follow that the health effects and the very ability of a person to even address the effects due to diminished resources would be equally devastating.”

She also noted victims’ diversity. “While there are typologies of victims, and we tied to make one, there is enough variance to indicate that healthy and frail alike--can fall prey to exploitation.”

MetLife’s Mature Market Institute, which is directed by Sandy Timmerman, spearheads research, national partnerships, and educational materials for “those in, approaching, or caring for those in the mature market.” The full study is available on the Institute’s website at 
www.maturemarketinstitute.

For more on elder financial abuse, including identity theft against elders, undue influence, and mass marketing fraud, visit my Web site at http://lisanerenberg.com/learn/learn.html.

From Daejeon to Cleveland: A World Elder Abuse Awareness Day Odyssey

This was the first year I participated in World Elder Abuse Awareness Day (WEAAD) events, and I did it to the hilt. WEAAD, the brainchild of Elizabeth Podnieks and the International Network for the Prevention of Elder Abuse (INPEA), has been gaining momentum since its 2006 debut, capturing the imaginations of program planners around the world. INPEA’s Web site provides a glimpse of the far-flung and creative programs it has inspired.

My whirlwind WEAAD tour started on June 3 in Daejeon, Korea where I took part in a symposium on elder suicide and abuse at the Chungnam Women’s Policy Development Institute. My very genial hostess Bae Ji Yeon, a researcher in social work at the Institute, greeted me in Seoul and accompanied me by train to Daejeon, where the event took place the next day. Bae is doing research exploring the link between elder abuse and suicide. Other presenters at the symposium included Japanese researcher Kaisho Yumiko, of the University of Shimane, Japan; and Donghee Han, Director of the Research Institute of Science for the Better Living of the Elderly in Busan, Korea. Donghee also directs the Korean Information Network for the Prevention of Elder Abuse (KINPEA).

Following the symposium and a little sightseeing, Donghee left for Busan where she was planning another WEAAD event scheduled for the following week, and I headed downtown with Bae and Kaisho for Korean barbeque. It's wonderful to see these passionate thirty-something researchers bringing new ideas, energy, and verve to our field.

In keeping with the Eastern gift-giving tradition, I’d prepared for my trip by stocking up on Americana gifts. Figuring that nothing was more emblematic of America these days than all things Obama, my Korean and Japanese colleagues got O-emblazoned socks, candy bars, and other presidential paraphernalia.

The next day, Bae dropped me at the Daejeon train station where I caught a high-speed train for the 2-hour ride to the beautiful port city of Busan. There, Donghee took time out from WEAAD preparations to meet me and show me the sights. Which included dropping in on a class of “Internet Navigators,” a group of seniors she organized who are learning how to use computer technology to build social networks and access information. Instructor Shin Tae Won teaches ambitious software programs like Photoshop as well as social networking, which students then go on to teach other seniors. When I told the group about my Web site, they logged on and converted it into Korean. So for my new Korean readers, I wish you a warm 환영합니다 네비게이터 여러분!

In the next few days, I met Donghee’s family (Michelle, Sasha, and Malia paper dolls for younger daughter Hadam, and socks for 16-year-old Hana, who incidentally, has already decided to follow in her mother's footsteps to become a gerontologist). I also sampled lots of wonderful Korean cuisine and took 5 a.m. walks along Haeundae Beach where I joined scores of health conscious Korean elders jogging, walking, and exercising at stations set up along the beachfront. Another highlight was the annual performance of the Busan Mothers Orchestra, which was organized many years ago to reduce isolation among stay-at-home moms. The audience consisted mostly of beaming kids, who were remarkably well behaved through the lineup of Mozart, Bach, and traditional Korean folk music--except for the few who couldn't help jumping up to wave at Mom.

On Sunday, the Japanese delegation arrived for the first Japanese/Korean international roundtable on elder abuse. The group was led by Toshi Tatara, past director of the National Center on Elder Abuse, and current professor at the Shukutoku University in Chiba; and included Akiko Sasaki, professor at the Graduate School of Health Sciences at Tokyo Medical and Dental University, and Noriko Tsukada, professor at the Nihon University Graduate School of Business. That afternoon, we visited the United Nations Memorial Cemetery, a tribute to the fallen soldiers from 16 countries who defended South Korea in the Korean War and the Busan fish market, which was billed in my guidebook as the smelliest fish market in the world (fortunately, the claim seemed to have been a bit overstated). That night, our hosts treated us to a feast--a prelude to the following day’s events--where we were joined by the Internet Navigators. I dodged requests to perform Karaoke and chatted with the Navigators about how they were using the Internet to keep in touch with grandchildren and finding other ways to stay involved.

The next morning we assembled at the Busan Metropolitan City Hall to meet with local officials and media reps before the WEAAD event, which featured performances by the Mothers Orchestra and traditional dance and choral groups followed by updates on abuse by the Japanese and Korean researchers. The panel was moderated by Dr. Sung Kyu Tak, who has written extensively about filial piety, the Confucian tenet of respect and duty toward parents, a value that many Koreans believe is fast eroding. Interestingly, Dr. Sung believes his work has received greater attention in the West than by Asians whom, he suspects, fear that promoting filial piety may be used as an excuse for government to relinquish responsibility for long term care. As the only non-researcher in the group, my charge was to describe abuse prevention policy and practice as well as provide an update on what’s new in the U.S.
The next morning I flew to Chiba at Toshi’s invitation to speak to a class of his graduate students at Shukutoku University. It was also a welcome opportunity to hear what Toshi has been up to since leaving the States. Among his recent accomplishments was translating the iconic National Research Council’s Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America (Bonnie & Wallace, 2003) into Japanese. The hefty 570 page English version translates to over 662 pages in Japanese and required the help of three professional translators and two years to complete. He’s since signed contracts to translate two more books for NAS, one on domestic violence and another on child abuse. He has also been working with Noriko Tsukada exploring public policy approaches to meeting Japan’s shortage of health care workers by encouraging foreign workers to come to Japan. In addition, he’s conducting a survey of domestic violence researchers to find out why there haven’t been more studies of secondary victimization of DV victims (by professionals involved with either the investigation or treatment processes).


Toshio’s students (who got tins of Obama breath mints) grilled me on everything from strategies for combating elder domestic violence to helpful hints for social work practice. In response to the latter, I advised them to abandon much of what they learned in social work school, which didn’t phase Toshi, who clearly enjoys challenging his students to question conventional wisdom and engage in open and lively debate. I genuinely appreciated the chance to brainstorm and spar with one of our field’s most creative and pioneering leaders.

The last stop on the WEAAD trail was Cleveland, Ohio, where I spoke at the Consortium Against Adult Abuse’s annual conference “Beyond the Looking Glass: Reflections of Adult Abuse, Interventions & Strategies.” I've always felt a special affinity to the Ohio Consortium since its development paralleled that of the San Francisco Consortium for Elder Abuse Prevention, and I’ve looked to them often for guidance and ideas. The conference, planned by Sylvia Pla-Rath and an education committee, clearly reflects their community’s longstanding commitment to dynamic networking and interdisciplinary exchange. The event also provided me with a chance to visit another of our field’s most respected and admired leaders, Georgia Anetzberger, who has, for nearly a quarter century, been a source of guidance, support, and inspiration.

Sadly, my WEAAD journey ended in Cleveland, and I won't be joining Elizabeth, Toshio, Donghee, Noriko, Akiko, and all the others in Paris for INPEA's official WEAAD commemoration, which takes place on July 5 in conjunction with the annual conference of the International Association of Gerontology & Geriatrics.

In my rush to get ready for the trip, I didn’t get around to plugging the National Center on Elder Abuse (NCEA)’s "Join Us: Together, we have the power to prevent elder abuse” campaign, so I'll do it belatedly. The campaign included the release of an elder abuse info-ad featuring actor William Mapother of TV's Lost, which ran in movie theaters from May 22 through June 18. Each year NCEA develops materials for states and local communities. In planning the trip, I also reconnected with Arlene Groh, a Canadian consultant who specializes in restorative justice approaches to elder abuse. Arlene spoke at the 2nd KINEA WEAAD event.

I’ve always found international exchanges to be both personally and professionally enriching, and WEAAD 2009 was certainly no exception. It was a chance to meet dynamic new colleagues and renew ties with the old. So, when it's time to start gearing up for WEAAD 2010, you can definitely count me in.

Secrets in America: New Documentary Focuses on Elder Financial Abuse

By the time David Jones emailed me to say that “our” film was finished, I’d forgotten all about it. It was well over a year since I’d met Stanislaus County’s Communications Director and it had taken that long to secure the funds and produce the half-hour long Secrets in America. With $12,000 in grants from the Stanislaus Community Foundation and Kaiser Permanente, David used friends and volunteers to shoot footage from San Francisco to Washington, D.C.

Despite the delays, the film is very timely, covering issues like predatory lending, lottery scams, and the sale of overpriced or worthless deferred annuities and reverse mortgages.

The film packs a powerful “neighbors looking out for neighbors” message through the account of Telvina Dias, who let two home repair cons into her home and was intimidated into writing them a check for a $2,500. Dias is exuberant as she describes how police, called by vigilant neighbor Jim Ross, nabbed the crooks. They’d approached Ross earlier, and he’d been watching Dias’ ordeal unfold. The film also emphasizes the importance of families looking out for elderly members and elders staying engaged with friends.

Actor Doris Roberts, best known for “Everybody Loves Raymond” makes an appearance. Roberts has participated in other Stanislaus County anti-abuse events and testified before Congress about elder abuse and ageism. You may recognize some other familiar faces.

One hundred DVDs were produced for senior centers, retirement communities, churches, and other venues; and nonprofit organizations can get copies for free. David also plans to pitch the film to PBS affiliates. To view it, click Secrets in America.

New Cal Law Allows for Video-Conferencing in Elder Abuse Cases

Among California’s new laws that went into effect on Jan 1 was AB 1158, which allows for the use of two-way video conferencing to examine witnesses who can't come to court. The new law may be a first step in tackling some of the obstacles posed by the 2004 US Supreme Court’s Crawford v. Washington decision, which was a major setback in the prosecution of elder abuse cases (even though the case didn’t involve elder abuse).

Here's the issue. Under the Sixth Amendment to the US Constitution, persons accused of crimes have the right to confront their accusers at trial. It limits the use of “hearsay,” or second-hand accounts made outside of courts, which often take the form of police officers conveying statements made by victims immediately after crimes are committed. These statements are particularly important in domestic violence and elder and child abuse cases because victims often recant their statements, and, under certain circumstances, their immediate responses are considered to be more reliable than those they make later. In elder abuse cases, there's the additional problem of victims not being able to come to court because they're ill, debilitated, or have relocated.

In the 1990s, advocates for victims of domestic violence, child abuse, and elder abuse sponsored laws allowing victims to avoid testifying in court in some situations. These included a 1999 elder abuse law (AB 526), which allowed juries to hear videotaped statements to police from elderly or incapacitated adults who were unable to come to court.

The Crawford case involved Michael Crawford, who was convicted of stabbing a man he believed had tried to rape his wife. The Supreme Court barred the tape-recorded, eyewitness account of the stabbing by Crawford’s wife, ruling that “testimonial statements” made out of court cannot be used at trial unless the person who made the statement is available for cross-examination. Statements are considered “testimonial” if they are knowingly made to law enforcement or government agents associated with law enforcement and provide evidence for later use in court. The court did not define the various types of testimonial statements that are covered, and subsequent cases are putting the definition to the test.

Still, the decision has had tremendous impact. It's restricted the use of evidence that was previously admissible and has been used to overturn convictions under child abuse and domestic violence laws. A state appeals court in San Jose used it to overturn California’s 1999 videotaping law.

Two-way video conferencing allows for victims who can't come to court to testify while protecting the rights of the accused to confront them. However, the use of "virtual confrontation" has been challenged in other settings, and it remains to be seen how it will be used in elder abuse cases. AB 1158 was sponsored by the San Francisco District Attorney and supported by the California District Attorneys Association, the California Senior Legislature, and the California Alliance for Retired Americans.

Mental Health Services for Vulnerable Elders

Many of us in California were disheartened to learn that as part of Governor Schwarzenegger’s plan to balance the budget, he wants to raid Proposition 63 funds. Prop 63 was a 2004 ballot initiative that imposed a 1% tax on millionaires to fund mental health services. The governor wants to use the funds to pay for existing programs instead of developing new services, something the initiative specifically forbids.

But according to Senate President pro Tem Darrell Steinberg, who championed Prop 63, the governor’s plan is "a non-starter." As a ballot initiative, any changes to Prop 63 have to be approved by the voters, and since the bill passed by a comfortable margin in 2004, that’s not likely to happen.

Those of us on the Archstone Advocacy Work Group hope that's the case. The group consists of reps from agencies that receive funds from the Archstone Foundation as part of its Elder Abuse Initiative. After hearing that few advocates for the elderly were participating in statewide Prop 63 “stakeholders” meetings, which set priorities for how the new money can be used, or applying for funds, our group produced a Fact Sheet that describes vulnerable elders’ mental health service needs and suggests ways that elder advocates can get involved.

The Fact Sheet is posted on the Web site of the Center on Excellence in Elder Abuse and Neglect. See Prop 63 and Elder Abuse.

Readers are welcome to use the Fact Sheet in California and beyond.