1. THE ROLE AND UNIQUE CHARACTERISTICS OF THE LONG-TERM CARE OMBUDSMAN PROGRAM JUNE 27, 2012

2. The Long-Term Care Ombudsman Program “…serves a vital public purpose. Every year the Long-Term Care Ombudsman Program helps many thousands of individual …residents …[and] the program can justly claim to have improved the system of long-term care services.” Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act Institute of Medicine, 1995, p. 11

3. History Growth in Nursing Homes – 1965 Medicare and Medicaid Provided public money for care What Happened – Abuse – Neglect – Substandard care – Fires resulting in deaths Publicity About Poor Care and Owner Profits Congressional Hearings 1970 Apparent that systems to protect individuals had failed Improvements in quality of care needed

4. Development Ombudsman Program - Idea developed by Dr. Arthur Flemming - Influenced by Swedish model - Proposed to President Nixon and included in his nursing home agenda in 1971 Presidential directive — help states establish units to respond to complaints made by or on behalf of individual patients Nursing Home Ombudsman Demonstration Projects contracts granted in 1972

5. Conclusion The laws and regulations enacted will be of little avail unless - “…communities are organized…to deal with the individual complaints of older persons living in nursing homes. - The individual in the nursing home is powerless.” AoA Commissioner Flemming 1976

6. Advocate Ombudsman Long-Term Care Ombudsmen are Advocates. LTCO carry the message for residents. LTCO are - impartial in gathering information. - advocates for residents in seeking resolution.

7. Long-Term Care Ombudsman Program (LTCOP) Is one of a kind within the Older Americans Act (OAA) Has several distinctions in definitions that set it apart from other service programs Is unique

8. “One of a Kind” Within the Aging Network (OAA) The Long-Term Care Ombudsman Program Operated by Office of the LTCO, headed by a State LTCO, responsible for a statewide program Has more strict confidentiality provisions Has specific conflict of interest provisions Pursues administrative, legal, and other remedies on behalf of residents Is protected from willful interference Has legal counsel available that is free of conflict of interest

9. Bottom Line The LTCOP is unique in OAA because it Addresses concerns of individual residents, Calls upon others to fulfill their responsibilities to residents, and Gives a public voice to residents’ needs by working for legislative and regulatory changes. Individual Concerns Systems Issues Laws, Regulations, Policies

10. Office of the LTCO Leading or supporting the Office of the LTCO may be a “climb” for everyone. Primary role is representing residents. Fulfilling this role may be viewed as -Refusing to be a team player, -Not being loyal to employer, -Being a “difficult” employee.

11. Distinctions in Definitions Sounds like__________, but it isn’t LTCOP and other programs use same terms but with different meanings Differences in definitions based on OAA

12. MISUNDERSTANDING Can Result It’s all about Definitions!

13. Distinctions = Strength Definitions based on OAA are the strength of the LTCOP

14. Investigation Agreement on purpose—to determine the facts How facts are used can be different with LTCO. - LTCOP gather information to resolve issue to resident’s satisfaction. - Others determine if a law, standard, or regulation has been violated.

15. Standards Of Evidence in Investigation LTCO gather evidence to - understand what must be addressed, - resolve problem to resident’s satisfaction. Other agencies gather evidence to - determine if legal standards have been violated and - take official action if indicated. Legal standards such as preponderance of the evidence, clear and convincing, or beyond a reasonable doubt

16. Law As End Or Beginning Law as End Point - Other agencies are bound by legal standards or regulations such as state survey agencies, Medicaid Fraud and Abuse Control Unit, adult protective services, and police departments. Law as Beginning - LTCO use law to see what applies but continue to work to get what resident wants even without a specific law or regulation that directly applies.

17. Confidentiality Lots of agencies and programs have confidentiality policies. OAA standards for LTCO are more strict. - Not allowed to share confidential information without consent. - Federal law takes precedence if state law conflicts.

18. Conflict Of Interest Many agencies and programs have conflict of interest policies. The LTCOP has OAA provisions - For program placement and - For individual ombudsmen. Additional dimensions for LTCOP from, Real People, Real Problems - Loyalty - Commitment - Control

19. What Exists in Your State? What regulations or policies do you have to deal with confidentiality and conflict of interest issues? - Are they consistent with the OAA? - Are these sufficient to address the issues discussed in this paper, History and Roles? - What type of training is provided on the regulations or policies of the LTCOP? How is this conducted?

20. What would you do? As a new SLTCO you’ve read the OAA provisions and many documents from the Ombudsman Resource Center and from your office bookcase. You meet with your supervisor to ask:  during the agency’s review of contracts process, when do I, as a SLTCO, make decisions about the proposed contracts for the local ombudsman programs,  how do I access specific budget information for the statewide program as well as for each local program, and  how do I work with the mail room and copy center because I need to send information to all the ombudsmen within the next week? You are stunned when your supervisor tells you that managers at her level, or higher, handle these activities. Of course you can read the proposed contracts but decisions about awarding the contracts are made by upper level management. Anything you want to mail must have prior approval and be included in the routine mailing to the field by the entire agency. This is not what you expected based on your understanding of the OAA.

21. What would you do? You sit on a task force examining systemic issues regarding the way deaths in nursing homes are handled. The media, spurred on by family members, has called for a review of “standard operating procedures” in the state. As law enforcement officers, surveyors, and adult protective services workers discuss how they investigate various types of complaints, you feel uneasy. You know that ombudsmen do not use the same investigative techniques that these others are describing. You suspect that when you explain how ombudsmen approach investigation everyone at the table will view the program as lacking in professionalism. You are concerned about the program losing credibility.

22. What would you do? An adult protective services case worker calls you seeking information about a client who lives in an assisted living facility. The worker wants to know what you discussed with the client and your observations. When you say you cannot share that information without the resident’s permission, the case worker raises her voice in reply, You are refusing to share information with me; yet you expect me to work with you in a cooperative relationship? I’m trying to help this woman! We have confidentiality standards, too, we’re both state employees. You’re just being an obstructionist!

23. What would you do? A charge nurse in a local nursing home applies for the local ombudsman position. The nurse calls you. She sounds angry and tells you that she is very upset with the Ombudsman Program in her area. The people responsible for filling the position said they cannot consider her because she is working in a nursing home! The nurse tells you some of her colleagues have immediately become nursing home surveyors after working in a nursing home. Why is the Ombudsman Program different? She only wants to help residents.

24. Uniqueness of the LTCOP Using everyday language, explain the aspects of the LTCOP that make it different from other OAA programs.

25. Your Role How do the unique aspects of the LTCOP impact your leadership of a statewide advocate ombudsman program?

26. The Long-Term Care Ombudsman Program Represents residents’ interests - Individual residents - Collectively before governmental agencies Encounters some misunderstanding of the LTCO role - Definitions of terms used by many agencies and programs are different for LTCOP - LTCOP definitions from the OAA add strength Operates differently from other programs by design. It is Unique!

27. Rewards Ombudsman perspective on the job: “The opportunity to speak up for someone who cannot do so for herself, to advocate for individuals or groups of people who otherwise might have no voice, no ‘seat at the table,’ keeps every day fresh and gives every meeting the potential to be important.” Esther Houser, Oklahoma State LTCO

28. Rewards Ombudsman perspective on the job: “The greatest experiences I have had working as an ombudsman are listening to people and treating them as a valued human being; working with citizens to become volunteer ombudsmen, and facilitating staff, residents, and families to communicate with each other.” Vivian Omagbemi, Maryland Local LTCO

29. The National Long-Term Care Ombudsman Resource Center (NORC) www.ltcombudsman.org The National Consumer Voice for Quality Long-Term Care (formerly NCCNHR) http://www.theconsumervoice.org/ This presentation was supported, in part, by a grant from the Administration on Aging, Department of Health and Human Services.