1. Moving Systems Advocacy Forward
Erin Pettegrew
Ombudsman Projects Coordinator
Office of the State Long-Term Care Ombudsman - Ohio

2. Objectives
Participants will understand the value of approaching problems at a systems level
Participants will share in a troubled facilities exercise idea they can adapt for their advocacy efforts
Participants will learn about systems advocacy efforts from two states’ perspectives.
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5. Ohio Example 1: Budget advocacy
Start early
Define & make your requests
Tell your story
Use data to back up anecdotes
Don’t be afraid to share your deficits
Enlist your stakeholders
Be a stakeholder to your partners
Trumpet your results
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6. Data in Budget Advocacy
Agencies created a NF performance spreadsheet during budget advocacy
SLTCO data: satisfaction survey results, verified complaints reports
Other sources: 5 star ratings, % Medicaid, facility size, profit status, cost per diem, staffing levels, reimbursement rates, etc.
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7. Results Big requests made smaller but still funded
Demonstrated the need
Telling a quality story:
Not-for-profit nursing facilities outperformed their for-profit counterparts
Smaller nursing facilities tended to have higher quality
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8. Profit/Not-for-Profit
CMS Star Ratings:
64 percent of not-for-profit facilities received four to five-star overall rating while 23% were rated one to two stars.
By comparison, 37% percent of for-profit homes earned four to five-star ratings, while 44% were rated one to two stars.
On average, the ombudsman program received 2x as many complaints about for-profit nursing homes than not-for-profit facilities (5.7 average complaints versus 2.5)
Employee retention is higher on average in not-for-profit facilities (80.6% versus 74.9%)
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9. Size matters
As facility size increases, the percentage of facilities with a five-star rating decreases (from 31% for 0-50 beds to 18% for beds).
As facility size increases, the percentage of facilities having a one-star rating increases (from 11% for 0-50 beds to 26% for beds).
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10. Ohio Example 2: Corporate Outreach
New corporation to the state
11 facilities
3 ombudsman regions
Met with leadership repeatedly
Provided data
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11. Verified complaints to the ombudsman program
Verified complaints to the ombudsman program. Explained terminology and that not all complaints are against the facility.
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12. Benefits Open door (phone) relationship
SLTCO and Corporate leadership
Local ombudsmen and the LNHAs
Cooperative relationship during a closure due to enforcement issue
Close eye on quality
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13. Ohio Example 3: Managed Care Outreach
Positioned as the managed care ombudsman
Relationships with Plans
Monthly calls
Quarterly stakeholder meetings with each Plan
Expectations for quality are upfront
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14. Benefits Stakeholder meetings Consumer publication input
Budget support
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15. Ohio Example 4: Troubled Facility Approach
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16. Background Frequent complaints in our data system (ODIS)
Anecdotal stories from ombudsmen about lack of cooperation and even outright obstacles from staff
Sister facility terminated from M/M certification – some of those residents moved there
New ombudsman was assigned
Program director reached out for help
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17. Approach
Data Dive
Homework assigned to regional ombudsman and state staff
WAR ROOM
No predetermined approaches
No predetermined outcomes
No blame shifting
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Data Source
Looking For
Findings
Survey History for 2 years
Annual surveys – citations
Very frequent complaint survey activity without citations
Complaint surveys – frequency & citations
Significant issues on annual surveys but corrected on revisit
Census trends
LNHA turnover – 3 in 6 months
Administrator history
Low census trending
Payor source breakdown – managed care, skilled, Medicaid
High skilled use (vent unit)
QIO project participation
Selection of projects
Not available
Participation history
Managed Care Plans
Level of involvement
Ombudsman not aware of involvement beyond required visits. Little managed care presence
Resident Council Minutes
Frequent complaints
Ineffective Resident Council
Staff follow-up history
Run by facility staff
Resident autonomy
Notes focused on staff announcements and improvements
No action steps or follow through
Satisfaction Surveys (if applicable)
Domains of concern
Direct care staff never spend enough time
Discrepancy between family and resident
Don’t trust that residents are taken care of when the family member is not present
Family involvement
Few activities of interest
Areas where the facility is much below statewide average
Nursing Home Compare data
Resident QMs vs statewide average
Clinical measures significantly above statewide average
Staffing vs statewide average
High staffing relative to statewide average (vent unit)
Ownership
Fines/enforcement
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Data Source
Looking For
Findings
Ombudsman verified complaint history for 2 years
Repeat complaints?
Almost three times the average number of complaints in a year
Frequency compared to statewide average
Frequent complaints about quality of care, pressure, infection control, discharge
Ombudsman case records
Repeat complainants?
Frequent administration turnover including DONs
Did complainant call Survey? Was it with Ombudsman help?
A couple of complainants also called State Survey without citations resulting
Consistent ombudsman assignment?
Ombudsman turnover not unusual
Working relationship with admin and direct care staff
Staff contentious in recent months
Very serious care concerns not adequately addressed by staff; residents either leave, decline or die, or stop complaining when nothing changes
Ombudsman advocacy and information activities for two years
Volunteer present?
No volunteer regularly assigned there
Consultation topics
Consultation topics are usually about ‘behaviors’ or smoking policy – desire to discharge resident
Consistently assigned ombudsman or volunteers
In-services
 No in-services in two years
Ombudsman institutional knowledge
Profile of the residents: age, presence of mental health issues
Younger population, serious drug issues, mental health diagnosis higher than other homes, transient histories
Facility environment: age, layout
Older building but renovated; institutional layout
Staffing: direct care staff involvement in decision making, retention and turnover
Younger population in the LTC unit with SPMI; variety in the vent unit
Relationship with ombudsman: combative or cooperative
Combative relationship in recent history
Finances: supplies, training, activities, staffing
No known issues with finances other than declining census, part of corporation
Special Focus Facilities designation?
Was SFF several years ago but graduated
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20. Strategies Assign a volunteer ombudsman
Ensure skills
Help residents making state survey complaints
Strategic and effective
Meet with new LNHA & corporate office
Meet with managed care plans & QIO
Build partnerships
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21. Results
TO BE DETERMINED……
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