Odd couple.

Wendy L. Bonifazi, RN, a contributing writer to Contemporary long Term Care, has been a volunteer ombudsman in Larimer County, Colorado, for nearly three years, where she now serves as special projects coordinator.

Providers and ombudsmen find common ground

Volunteer ombudsman Bill Jordan was admitted to the Milford Nursing Home under false pretenses: a 48-hour "recuperation" from a fictitious hospitalization. His true goal? Uncovering problematic practices. He scrutinized everything, noting how long he waited for an alternate meal and extra butter, the response time to answer call lights, hallway conversations, how night staff treated residents.

When employees of the New Hampshire nursing home discovered Jordan's duplicity, they also discovered his co-conspirator: Administrator Jeffrey Schwartz. "I instructed him to use all his senses to track every experience--what he saw, heard, and smelled, how it touched him for good or for bad--then share his findings in an exit survey with the admissions team,' Schwartz recalls.

Schwartz recruited Jordan as part of Milford's CQI process to improve admissions procedures and residents' initial adjustment. "I took a chance, but felt the positives would outweigh any negatives," he says. "It did a lot to help Bill understand the resident's experience, and enhanced his appreciation of what we do in a nursing home. He learned the difficulties of dealing with combative residents, answering five bells rung simultaneously by residents wanting to go to sleep at the same time, and what it's like to have a noisy roommate who keeps you up all night with trips to the bathroom."

Further, the facility's commitment to patient care impressed ombudsmen and surveyors, says Schwartz. "Back then [over four years ago], CQI was the big initiative. For three years, state surveyors touted the experience."

Schwartz, now administrator of Mariner of Merrimack Valley, a skilled nursing and rehabilitation facility in Amesbury, Massachusetts, still fosters proactive relationships with ombudsmen. "The better the relationship, the better your facility can be," he says.

Yet, more often than not, the relationship between ombudsmen and providers is cautious, chilly, or antagonistic.

Enemies or allies?

In part, that depends on where you are. In some states, conflict is the rule; in others, it's the exception.

New Hampshire is one state where the relationship seems to be working. A survey of New Hampshire providers last year asking for their thoughts about the ombudsman program yielded an 80 percent return and an overwhelmingly favorable response to the program. The two most common complaints were delays in receiving written reports and lack of ombudsmen volunteers in some facilities.

"It takes two to build relationships," says Judith Griffin, New Hampshire state long term care ombudsman. "If providers see us as enemies instead of assets, we're forced to behave that way. But our focus is on collaboration and cooperation whenever possible, to help them do the best job they can."

Collaboration is working in North Carolina as well. "I get more and more calls from administrators asking for help and information," says Lottie Massey, lead regional ombudsman for eight North Carolina counties. "They'll say 'Here's my problem, here's what I tried, can you help with this particular situation?'"

Massey and her staff provided 169 consultations last year on dilemmas ranging from problem behaviors to resident rights, transfers, and discharges. The three staff ombudsmen also provided in-services on dementia, dignity, difficult behaviors, rights, and regulations.

That kind of demand stems as much from credibility as visibility. Massey is a former DON, the other two ombudsmen are social workers, and all three once worked in long term care. The providers they work with "know we see their side, know the situations, and understand where they're coming from and what they're going through," says Massey.

That high level of expertise also extends to many of the 171 volunteers in Massey's eight-county area, who include nursing home social workers, home health nurses, nursing professors, and administrators. Each volunteer serves on a subcommittee responsible for quarterly monitoring and interim visits for approximately five facilities, plus "friendly visits" to establish rapport.

During the official, unannounced quarterly monitoring visits (some conducted on nights and weekends), teams of three or more volunteers conduct room-by-room visits, meeting every resident possible, to identify both violations and favorable observations. "We look for positive comments and behaviors, pleasant attitudes and environments," says Massey. "We let staff know we notice, because it makes them want to do their jobs better."

After several hours, the volunteers regroup, compare findings, then give the administrator their observations on the environment, employee interactions, food preparation and presentation, and operations. Then they complete a public record, which goes to the ombudsman for review and follow-up. That record is shared with administrators, consumers, and surveyors in preparation for surveys. "The volunteers function as observers," says Massey. "They look at how the facility upholds resident rights and suggest improvements.'

For the past eight years, North Carolina volunteers have also planned, arranged, and hosted a resident rights celebration which has grown from its origins as a senior center luncheon. One county hosts a celebration in every facility for residents; others host park cookouts, scavenger hunts, even a party for residents under 50 at a comedy club.

North Carolina's ombudsman-sponsored programs include day-long programs for facility staff, a dementia training conference, and organizing structured family council meetings. "We often suggest family councils to administrators to organize and help them support families," says Massey. "We make sure they're not gripe sessions and now have regional family councils that are very active writing and visiting legislators."

Individual advocacy means taking on families, friends, and even government agencies. After trying for two years to collect overdue Social Security payments, a Texas nursing home resident and his family succeeded when volunteer ombudsman Dick McMahan threatened to bring the resident, a legislator, and the media with him.

Complaints, complaints, complaints

"Ombudsmen aren't enforcers or regulators, they're advocates," says Rebecca Holder, a former regional ombudsman who is now the health care administrator of Triad United Methodist Home, a continuing care retirement community in Winston-Salem, North Carolina. "Advocacy goes both ways, including on behalf of facilities with residents, families, or surveyors. The bottom line is they're advocates for better care, and that's what both sides want."

But not all ombudsmen see their roles as collaborative. Some revel in their reputations as "pitbulls with lipstick" who tenaciously attack problems until they make progress. And no wonder, considering the program's history.

Legislators enacted the Long Term Care Ombudsman Program in the 1970s, in response to widespread public concerns about nursing home quality. Ombudsmen were to provide advocacy both for individual elderly nursing home residents and for major policy changes. In 1978, amendments to the Older Americans Act required states to develop statewide ombudsman programs and reporting systems and mandated that nursing facilities give ombudsmen access to facilities, residents, and records. Coverage expanded to board and care facilities in 1981.

Regional and local ombudsmen investigate complaints and implement programs under direction from the state ombudsman, who is responsible for program administration and legislative advocacy. Most ombudsmen are volunteers rather than paid staff (see "Running on empty"), but volunteers are also authorized to visit facilities, have access to residents and records, and perform other functions. More than half may also investigate complaints.

And they get plenty of them. According to the Administration on Aging's most recent Long Term Care Ombudsman Report, ombudsmen handled 179,111 complaints in 1996, of which about 30 percent came from residents, 20 percent from staff, 26 percent from friends and families, and 13 percent from ombudsmen and on-site observation. Eighty-one per cent of the cases they closed that year involved nursing homes; 17 percent were in board and care homes.

A 1999 Office of Inspector General report based on a 10-state survey found had risen that complaints had risen 44 per cent since 1989. Major increases were in resident care and resident rights, including insufficient staff and training, hydration, malnutrition, evictions, and abuse.

Improving relations

Ombudsmen are mandated to look for trouble, barraged by consumer complaints, and battered by providers' hostility. That makes it tough to maintain objectivity and a positive outlook, particularly for volunteers and entry-level local ombudsmen who are unfamiliar with aging or institutional life.

"Most volunteers lack knowledge of long term care, and they may have preconceptions or axes to grind," says Rick Abrams, president of the New Jersey Association of Healthcare Facilities and former state ombudsman. "You have to designate time to dispel myths and educate volunteers and regional coordinators to the whole range of services. When facilities educate advocates, ombudsmen become advocates for facilities."

Administrator Schwartz suggests taking the initiative. "Set meetings to introduce them to your staff, resident council, and family council. Have them for meals. Make sure your ombudsman understands the issues you deal with daily. Help them learn the facility, what's realistic and what's not. Bring them into potential problems with residents and families."

Administrators can also help educate ombudsmen by inviting them to attend in-services or to follow a CNA for a day.

Abrams recommends designating an ombudsman liaison (preferably the administrator or another manager) to provide orientation, introductions, and a direct channel for complaints and communication.

Make sure your liaison gives your ombudsman advance notice about potentially sticky problems. "If you have a potential discharge for nonpayment, let the ombudsman know you're issuing it and send a copy," advises ombudsman Massey. "Prepare ombudsmen for resident and family calls, and let them know if you're willing to work out a payment plan. By communicating, you can make it a cooperative venture."

And don't forget that ignorance and defensiveness can work both ways. "One of the first things administrators can do is to educate staff about who we are and why we're there, particularly with increased night and weekend visits," says Massey.

Encouraging your ombudsman to participate in facility events can also foster good relations. Administrator Holder suggests inviting ombudsmen to participate in such gatherings as family and resident barbecues and in community activities, such as civic groups or community boards.

Asking for help, whether in drafting a plan of correction or remodeling a facility, is another bond-builder. "Ombudsmen want to help," Holder points out.

And remember, your attitude may determine whether you reap the fruits of collaboration of suffer the frustration of endless resistance and suspicion. "Be proactive, rather than reactive," advises Schwartz. "You'll be way ahead."

Running on empty

At the urging of disgruntled ombudsmen, the Institute of Medicine evaluated the program in 1995. The study concluded that the program needed more staff--particularly paid employees-and more fiscal support.

The committee commended ombudsmen for their role in helping to bring about improvements in long term care, including "the Federal Nursing Home Reform Law of 1987 (in particular, provisions pertaining to quality of care and quality of life); increased personal needs allowances; protections from involuntary discharge and room transfer; reduced use of physical restraints; improved building and safety standards; increased state funding for inspection and surveying; reduced use of psychotropic medications; better licensing oversight of health care professionals; increased use of advanced directives; stronger LTC staff competencies and sensitivities; and empowerment of residents through stronger resident and family governance structures."

But, the report continued, these advances were achieved "despite considerable barriers in most, if not all states. Obstacles to performance include inadequate funding, resulting staff shortages, low salary levels [editor's note: some local ombudsmen with bachelor's degrees earn as little as $14,500 per year, less than some CNAs], structural conflicts of interest that limit the ability to act, and uneven implementation among and Within states."

Ombudsman programs rely heavily on volunteers, with an estimated 882 full-time equivalent paid staff, 6,764 state and local volunteers certified to investigate complaints, and 6,035 non-certified volunteers (per preliminary Administration on Aging data for 1997).

Even counting volunteers, there are too few ombudsmen to do the job Congress intended. The study recommends hiring 300 more ombudsmen to lower the ratio from 2,700 beds to 2,000 beds per full-time professional.

Programs are funded by local, state, and/or federal sources. Last year, federal funding was increased from $4,449,000 to almost $7.5 million. The good news is that this was the only Older Americans Act Title to get a significant increase in hinds, says Alice H. Hedt, director of the Washington, D.C.-based National Long Term Care Ombudsman Center, but the bad news is that it's still minimal funding: "Thirteen states' ombudsman funding is just $37,245 per year, the minimum permissible." Total ombudsman program funding is just $96,000 in geographic giants like Montana and Wyoming, making it difficult for ombudsmen to cover their far-flung facilities.

Low funding makes it hard to recruit and retain ombudsmen. It also makes it necessary to rely heavily on volunteers--and hard to train or supervise them adequately. Ombudsmen commonly report they are so overwhelmed by complaints, and by the time needed to deal with residents and family concerns, that they can't recruit and supervise new volunteers or provide other services. "Daily, state and local ombudsmen tell us demands on the programs far exceed resources," says Hedt. "They're frustrated by lack of time."

Some volunteer training programs cram state and federal residents' rights, complaint resolution, communication, and other matters into just a few sessions. Others have additional requirements, including several days of supervised on-site training, more intensive training for those certified to resolve complaints, and continuing education programs. Nevertheless, "we're on the phone constantly, providing instruction, advice, and support," says Barbara Fraser, program manager for the state of Georgia.

Through the years

Early 1970s

The Public Health Service funds ombudsman demonstration programs in Idaho, Michigan, Pennsylvania, South Carolina, and Wisconsin.

1975

The Administration on Aging assumes responsibility for the Long Term Care Ombudsman Program.

1978

Older Americans Act amendments require states to develop statewide programs; assure access to residents, facilities, and records; and develop procedures for record. disclosure, confidentiality, and statewide reporting.

1981

OAA extends ombudsman services to board and care facility residents.

1988

The National Long Term Care Ombudsman Resource Center is created by the National Citizens' Coalition for Nursing Home Reform and the National Association on State Units on Aging.

1992

OAA reauthorization links the ombudsman program to other beneficiary services through Title VII.

1995

The Institute of Medicine publishes a comprehensive study of the program. (See "Running on empty")

1998

Funding is increased from $4,449,000 to $7,449,000 to enable ombudsmen to maintain regular presence in facilities.

1999

Communities request ombudsmen services for people receiving managed care, home care, and other services.

PRIMARY SOURCE: NATIONAL LONG TERM CARE OMBUDSMAN RESOURCE CENTER.