Ombudsman Program Process Evaluation: Progress and Initial Data 2017 National Consumer Voice for Quality Long-Term Care Conference, Arlington, VA November 6, 2017 Kim Nguyen, PhD, NORC Louise Ryan, MPA, ACL/AoA Susan Jenkins, PhD, ACL/AoA

Evaluation Team NORC at the University of Chicago (NORC) Process Evaluation and Special Studies Related to the LTCOP NORC at the University of Chicago (NORC) National Consumer Voice for Quality Long-Term Care (Consumer Voice) Brooke Hollister, PhD, University of California, San Francisco Helaine Resnick, PhD, Resnick, Chodorow & Associates William Benson, Health Benefits ABCs Human Services Research Institute (HSRI)

Research Questions Process Evaluation and Special Studies Related to the LTCOP How is the LTCOP structured and how does it operate at the local, State, and Federal levels? How do LTCOPs use existing resources to resolve problems of individual residents and to bring about changes at the facility and governmental (local, State, and Federal) levels that will improve the quality of services available/provided? With whom do LTCOPs partner, and how do LTCOPs work with partner programs? How does the LTCOP provide feedback on successful practices and areas for improvement?

Data Collection Round 1 Data Collection Round 2 Data Collection Process Evaluation and Special Studies Related to the LTCOP Round 1 Data Collection Telephone Interviews Federal Staff (5) Stakeholders (19) State Ombudsmen (53) Round 2 Data Collection Online Surveys State Ombudsmen (census) Local Directors/Regional Representatives (sample) Local Representatives (sample) Volunteers (sample)

the transcriber heard… Transcription Errors Round 1 Data Collection Instead of “systems advocacy,” the transcriber heard…

“assistance advocacy.” Transcription Errors Round 1 Data Collection “assistance advocacy.”

the transcriber heard… Transcription Errors Round 1 Data Collection Instead of “ombudsman,” the transcriber heard…

Transcription Errors Round 1 Data Collection “embossment.”

Transcription Errors Round 1 Data Collection [inaudible]

the transcriber heard… Transcription Errors Round 1 Data Collection Instead of “Alzheimer’s Association,” the transcriber heard…

“Old Timers’ Association” Transcription Errors Round 1 Data Collection “Old Timers’ Association”

“My systems advocacy agenda is surviving the day.” Outtakes Round 1 Data Collection On developing a systems advocacy agenda… “My systems advocacy agenda is surviving the day.”

“I call it the shampoo approach. Rinse and repeat. Start all over.” Outtakes Round 1 Data Collection On the continual re-education of coordinating entities and stakeholders, due to staff turnover… “I call it the shampoo approach. Rinse and repeat. Start all over.”

Respondent: “Well, you haven’t seen the drivers.” Outtakes Round 1 Data Collection On challenges facing the Ombudsman Program… Respondent: “[The program] isn’t sexy like home- delivered meals. That’s where it’s at.” Interviewer: “I honestly have never heard of the meals program being described as ‘sexy’.” Respondent: “Well, you haven’t seen the drivers.”

Preliminary Findings The Long-Term Care Ombudsman Program is unique… Round 1 Data Collection: Stakeholders and Federal Staff The Long-Term Care Ombudsman Program is unique…

Preliminary Findings and… confusing… Round 1 Data Collection: Stakeholders and Federal Staff and… confusing…

multiple levels. Preliminary Findings on Round 1 Data Collection: Stakeholders and Federal Staff on multiple levels.

Preliminary Findings Uniqueness of Program Mission Structure Round 1 Data Collection: Stakeholders and Federal Staff Uniqueness of Program Mission OAA Federally mandated to advocate for individuals living in facilities Role of the Ombudsman Structure Requirement for independence Reporting Funding Volunteers Heavy reliance on volunteers in delivering services Attracts individuals with professional backgrounds Work characterized by a high level of responsibility

Preliminary Findings Strengths of Program Mission Structure Round 1 Data Collection: Stakeholders and Federal Staff Strengths of Program Mission Serves as the voice of long-term care residents Structure Access to residents and greater flexibility in addressing issues than other entities (such as licensing and certification) Degree of independence afforded to the Ombudsman Program Staff and Volunteers Passionate, knowledgeable, committed Direct, face-to-face interactions with individuals

Preliminary Findings Program Visibility/Awareness Stakeholders Round 1 Data Collection: Stakeholders and Federal Staff Program Visibility/Awareness Stakeholders High visibility within aging service network Factors facilitating visibility of program Efforts of Kathy Greenlee and Becky Kurtz Participation in coalitions, taskforces, etc. Implementation of Final Rule Consumers Awareness is low at the consumer level Among current residents, awareness is on an as-needed basis. Among prospective residents, visibility is lower.

Preliminary Findings Program Effectiveness Round 1 Data Collection: Stakeholders and Federal Staff Program Effectiveness Overall, the LTCOP is perceived to be effective. Effectiveness also understood to vary across and within states. Basis of Assessment (Metrics Used) Observations and Anecdotes Direct experience with complaint handling process Stories shared by State Ombudsman or other stakeholders regarding activities Interactions with State Ombudsman at trainings and conferences NORS data Frequency of visits, description of resident concerns and how they were addressed

Preliminary Findings Program Structure Round 1 Data Collection: State Ombudsmen Program Structure Types of state LTCOP structures: State-level: Most often in an SUA, but can be in another state government agency or a nonprofit Local level: Centralized or decentralized (local programs in AAAs or other entities) Trade-offs with each type of organizational placement: Location in an SUA or related government agency allows access to a variety of resources and facilitates relationships to coordinating entities Location in an independent state agency or nonprofit facilitates autonomy SUA support is valuable regardless of structure Final Rule helped clarify LTCOP role and need for autonomy within program structure

Preliminary Findings Resources and Program Capacity Round 1 Data Collection: State Ombudsmen Resources and Program Capacity Insufficient funding commonly reported as a challenge and source of frustration to provide desired level of service, or in many cases, service to meet federal mandates Funds were perceived to be insufficient with respect to staffing, salaries, travel, and data systems However, some ombudsmen did feel that their program has sufficient funding to carry out responsibilities Ombudsmen noted the need to identify and advocate for resources to supplement federal funding to ensure program success

Preliminary Findings Resources and Program Capacity Round 1 Data Collection: State Ombudsmen Resources and Program Capacity Many programs struggle to visit all long-term care facilities quarterly and to conduct non-complaint-related visits Barriers to regular visits include staffing, distance of facilities from local programs Some reported difficulty taking on fiscal management responsibilities (OAA and Final Rule requirement) due to lack of expertise and sufficient access to budget information

Preliminary Findings Prioritizing Resources Round 1 Data Collection: State Ombudsmen Prioritizing Resources Funding challenges compel State Ombudsmen to prioritize resources and program activities Programs may prioritize: Facility visits and individual case work over systems advocacy Case/complaint work over non-complaint visits Cases where a resident’s health or safety is at risk Visits to some facility types (such as nursing homes) over other facility types Handling cases over the phone when possible (to reduce travel costs)

Preliminary Findings Volunteers Round 1 Data Collection: State Ombudsmen Volunteers Successful recruitment strategies included the following: Working with an educational institution to recruit students with community service requirements Human interest stories in the media that highlight the LTCOP and the difference it has made in the lives of those served Media stories about volunteers Advertising through radio, television, and newspapers Outreach in community settings such as churches, health fairs, and senior centers Working with AARP to educate members about the program

Preliminary Findings Volunteers Round 1 Data Collection: State Ombudsmen Volunteers Successful management strategies included the following: Hiring a volunteer coordinator to help recruit, train, and supervise volunteers Potential benefits: Increase volunteers Improve training Support volunteers in addressing challenging issues, may reduce stress and help with retention Interested volunteers required to shadow another volunteer before they undergo training Allows the prospective volunteer to better understand the role and confirm their interest Ensures commitment before investing valuable staff time in onboarding process

Preliminary Findings Coordinating entities Round 1 Data Collection: State Ombudsmen Coordinating entities Benefits. Many ombudsmen described relationships with coordinating entities as positive and critical to carrying out their work. State agencies and other stakeholder organizations assist the program with: Providing referrals to services and resources to residents Supporting systems advocacy work to improve quality of care for residents Providing the “teeth” to compel nursing homes and facilities to improve care Education on how to meet the needs of special populations Barriers. Developing relationships can be challenging due to: Lack of understanding of the LTCOP’s role and responsibilities Different perspectives or priorities Time constraints for staff at both LTCOP and coordinating entities

Looking Ahead Process Evaluation – Round 2 Outcomes Evaluation Upcoming Data Collection Process Evaluation – Round 2 Online Surveys State Ombudsmen (53) Local Directors/Regional Representatives (27 states) Local Representatives (27 states) Volunteers (27 states) Outcomes Evaluation Longitudinal Study Interviews Focus Groups

Kim Nguyen, PhD 301-634-9495 nguyen-kim@norc.org