Maryland Long-Term Care Ombudsman Program : A Plan for Ombudsman Excellence

1. Maryland Long-Term Care Ombudsman Program:A Plan for Ombudsman Excellence Health Benefits ABCs For Maryland’s LTCOP Health Benefits ABCs LLC

2. Ombudsman Work Required By State And Federal Law • Investigate Complaints • Resolve Complaints • Educate Residents And Families • Monitor Laws, Regulations, Policies, Actions • Advocate For Legislative And Administrative Policy Changes Health Benefits ABCs LLC

3. UnderlyingPrinciples Advocacy • Ombudsmen speak for people who have rights but have little or no power or voice; • Ombudsmen work for residents (not for agencies, facilities, or even residents’ families) • The LTCOP must be a statewide, cohesive program. Health Benefits ABCs LLC

4. Health Benefits ABCs’ Goal Help the MDoA . . . • be a wise manager of this program • move the SLTCOP forward on the path to excellence Health Benefits ABCs LLC

5. Health Benefits ABCs did: • Conduct a thorough review and assessment of the Maryland LTCOP • Identify how processes and systems could be strengthened. Health Benefits ABCs LLC

6. Maryland LTCOP Project • Gathered and analyzed data • Reviewed written material • Conducted town hall meetings of Ombudsmen • Conducted focus groups of stakeholders • Convened stakeholders to review findings and recommendations • Interviewed staff and other stakeholders in the LTCOP to obtain insights about the program • Reviewed material from other state ombudsman programs Health Benefits ABCs LLC

7. What Is In Our Report

8. Key Findingsand Recommendations Health Benefits ABCs LLC

9. Organization SLTCO must assist, guide, and oversee 19 local ombudsman programs Health Benefits ABCs LLC

11. Local Entities Per State Office Staff Benchmark States, 2007 (Lower Ratios Indicate Better Coverage) 25 19.0 20 15 10 3.5 3.5 4.3 5 2.8 0 Georgia Oklahoma Washington Maryland Avg 3 Benchmark States

12. Recommendations • Ensure the SLTCO Has Unimpeded Access throughout the Department • Reduce the Number of Local Programs (if funding cannot be substantially increased) Health Benefits ABCs LLC

13. Governance State Ombudsman has very limited authority to govern the program as envisioned by the Older Americans Act. • Regulations not up to date • No LTCOP contract • No standards and process for designating local entities • No process for designating or certifying ombudsmen based on their qualifications and absence of conflicts of interest Health Benefits ABCs LLC

14. Recommendations • Standards and a process for designating entities that sponsor local programs as representatives of the Office of SLTCO • Specific, written agreements with local programs • Certification of ombudsmen Health Benefits ABCs LLC

15. Human Resources State office of the SLTCO is severely understaffed, compared with other states Health Benefits ABCs LLC

17. Human Resources, continued The State Ombudsman’s salary is far below those of other states Health Benefits ABCs LLC

19. Local Program Staffing Statewide average of the number of long-term care beds per local program staff (FTEs) in Maryland is 2.44 times better than the average in most other states This workload is not evenly distributed across the local programs Health Benefits ABCs LLC

21. More time with group activities

22. Recommendations • Raise salary of SLTCO • Require no less than one (1) full-time ombudsman in each program, whose duties are not divided with other services or programs • Study the workloads of local LTCOs, with special attention to the division of their duties with other programs • Place strong emphasis on the recruitment and management of volunteers. Health Benefits ABCs LLC

23. Finance(Note) To compare Maryland’s expenditures with other states, we converted dollars into “National Average Dollars.” This takes into account the relatively higher cost of living in Maryland. Health Benefits ABCs LLC

24. Finance • Maryland’s total expenditures, including federal, state, and local funds, have increased 214% since Federal FY 2000 • Maryland spent $41.13 dollars per resident (bed). (This amount is $12.44 higher per bed than the national average and $13.81 above the average expenditures of the States with similar budgets.) Health Benefits ABCs LLC

26. Finance, continued Funds have been distributed without use of a comprehensive allocation formula Health Benefits ABCs LLC

28. Recommendations • Review expenditures and increase funding where necessary; and • Distribute funds to local agencies using a needs-based methodology. (We have provided examples of four alternative funding formulae) Health Benefits ABCs LLC

29. Individual Advocacy Maryland well below the national average in: • percent of complaints verified, • percent of complaints with a positive outcome, • percent of complaints resolved to the satisfaction of the resident or complainant, and • percent of facilities visited on a regularbasis (quarterly). Health Benefits ABCs LLC

30. Maryland Receives a Disproportionate Number of Complaints from Facilities (vs. Residents or Families) Health Benefits ABCs LLC

32. Recommendations for Individual Advocacy • Promulgate revised regulations • Revise the Procedures Manual • Pursue administrative and legal remedies on behalf of residents Health Benefits ABCs LLC

33. Systems Advocacy • Most ombudsmen have engaged in limited systems advocacy work • Ombudsmen have seldom entered the legislative and rule-making arena on behalf of residents’ concerns and problems Health Benefits ABCs LLC

35. Recommendations • Change Maryland policies, rules, or laws, or program structure to enable the LTCOP to fulfill mandated responsibilities for systems advocacy; • Use program’s statistical data • to identify systems advocacy goals • develop positions for the program use the annual report as a tool for advocacy; • Strengthen SLTCOP relationships with other organizations to pursue common advocacy goals. Health Benefits ABCs LLC

36. Program Awareness • Local programs engaged in 345 community education activities and 14 interviews/discussions with the media, and issued 26 press releases. • Many community education activities dealt with elder abuse prevention outside of nursing homes Health Benefits ABCs LLC

37. Recommendations • Significantly increase public awareness • media contacts and public appearances, • actively make legislators aware of the work and benefits of the program. • Prepare uniform statewide materials • Advertise the State program • Annual report • Attractive as possible • Convey information about the program and long-term care issues • Distribute widely Health Benefits ABCs LLC

38. Volunteers • 11 local programs have volunteers (8 do not) • 103 volunteers in Maryland in 2007, mostly in two programs • Several programs report having 3 or less volunteers • Support for these volunteers not adequate • Lack of guidance, support, and resources from the SLTCOP regarding volunteer management • Variation in policies and approaches to volunteer management. Health Benefits ABCs LLC

40. Recommendation Employ a full time, well-qualified, volunteer management expert to guide, support, and assist with volunteer management throughout the State. Health Benefits ABCs LLC

41. Training • Training does not comply with the federal responsibility • to assure that representatives of the State Ombudsman have the specified training • to assure that persons are approved as qualified before serving as ombudsmen • Orientation training does not use effective components that many states use as part of a certification process • Indicators for qualifying new ombudsmen are too few • Ongoing training could be more effective Health Benefits ABCs LLC

42. Recommendations • Totally revise • orientation and certification process • manual • Use various training approaches for ongoing training sessions • Conduct an Annual Statewide Conference. Health Benefits ABCs LLC

43. Accountability and Quality Improvement The program: • does not use ombudsman-specific written agreements that promote accountability to the SLTCO • lacks a formal process for designating and de-designating local programs • lacks certification standards for ombudsmen • needs to enhance review of performance and expenditures Health Benefits ABCs LLC

44. Recommendations • Ombudsman program-specific agreements between the MDoA and the sponsoring agencies • Improve monitoring tools and processes • Begin a process of Continuous Quality Improvement Health Benefits ABCs LLC

45. Data Collection and Reporting • Maryland LTCOP has effective system for collecting and analyzing data • Data accuracy and consistency needs constant monitoring and improvement • Use of data is severely limited • Ombudsmen find themselves using an extraordinary amount of time in data entry and reporting Health Benefits ABCs LLC

46. Recommendations • Culture that includes the use of statistical information • Work constantly to improve data accuracy and consistency • Reduce the effects of data entry and reporting on ombudsmen’s workload, if possible Health Benefits ABCs LLC

47. Effectiveness • Examples of effective work from the Eastern Shore to the mountains • Missing: assurance that every resident, in each facility in the State, can expect equally useful, assertive representation • We cannot say, unequivocally, that the program is effective and that all of its representatives are doing the best possible work on behalf of residents Health Benefits ABCs LLC

48. Essentials • Not a statewide program governed by the SLTCO (or MDoA) • a network of individual local programs with the same name • inconsistencies and lack of economy of scale • Govern the program from the state – OSLTCO. • The 19 programs either need to be funded far better OR • have fewer programs.  • Funding allocation needs to be driven by need (beds, facilities) • Increase resident-driven complaints • Active systems advocacy Health Benefits ABCs LLC

49. Key Recommendations • Enhance and reorganize the state office of the SLTCOP, assuring that the SLTCO has unimpeded access to other functions within the MDoA • Assure the legal authority for the program to conduct systems advocacy and implement a thoroughgoing process of systems advocacy Health Benefits ABCs LLC

50. Key Recommendations, 2 • Assure adequate funding of the program as a whole and distribute funds to local agencies using a needs-based formula • Consider the effectiveness and efficiency of number of local programs and reduce their number if sufficient funding is not available Health Benefits ABCs LLC