The Role of Long-Term Care Ombudsman Programs in HCBS: Overview and Findings from the National Evaluation of the LTCOP

2018 HCBS Conference

August 29, 2018

Kim Nguyen, PhD 

Sarah Downie, MPP

NORC at the University of Chicago

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National Evaluation of the LTCOP

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Overview of LTCOP

A long-term care Ombudsman (representative of the Office) is an advocate for residents of long-term care facilities.

Each state has an Office of the Long-Term Care Ombudsman that is led by a State Long-Term Care Ombudsman (SLTCO)

53 programs, including Guam, Puerto Rico, and Washington DC.

Many programs rely on volunteers to maintain an ongoing presence in facilities

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Overview of LTCOP

As authorized by the Older Americans Act (OAA), the Long-Term Care Ombudsman Program (LTCOP) has the following responsibilities:

Identify, investigate, and resolve complaints made by or on behalf of residents of long-term care facilities 

Provide information to residents, families, staff

Advocate for systemic changes to improve residents’ care and quality of life

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Evaluation Team 

Process Evaluation and Special Studies Related to the LTCOP

NORC at the University of Chicago (NORC Chicago)

National Consumer Voice for Quality Long-Term Care (Consumer Voice)

Brooke Hollister, PhD, University of California, San Francisco

Helaine Resnick, PhD, Resnick, Chodorow and Associates

William Benson, Health Benefits ABCs

Human Services Research Institute (HSRI)

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Background  

Overview of National Studies on the LTCOP

1993-1995: Institute of Medicine (IOM) completed the first 		 national evaluation of the LTCOP.

2011-2013: NORC and its partners developed a 			 comprehensive evaluation design of the 		 LTCOP.

2015-2018: NORC and its partners are conducting a 		 process evaluation of the LTCOP.

2018-2021: NORC and its partners are conducting an 		 outcome evaluation of the LTCOP.

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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 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?

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Data Collection 

Process Evaluation and Special Studies Related to the LTCOP

Round 1 Data Collection (2017)

Telephone Interviews

Federal Staff (5) √

Stakeholders (19) √

State Ombudsmen (53) √

Round 2 Data Collection (2018)

Online Surveys

State Ombudsmen (98% in 53 states) √

Local Ombudsmen – Leads (@ 80% in 27 states) √

Local Ombudsmen (@ 63% in 27 states) √

Volunteers (@50% in 26 states) √

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Data Collection

Round 2 Local Data Collection (27 States) 

AoA Region
| 1  | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |
|----|----|----|----|----|----|----|----|----|----|
| ME | NJ | DE | FL | IL | LA | IA | ND | AZ | AK |
| RI | NY | VA | KY | IN | NM | NE | SD | CA | WA |
| -  | -  | -  | TN | OH | -  | -  | -  | HI | -  |
| -  | -  | -  | SC | MN | -  | -  | -  | NV | -  |
| -  | -  | -  | -  | WI | -  | -  | -  | -  | -  |

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Outcome Evaluation

Upcoming Data Collection

Longitudinal Study

Interviews, Surveys, Focus Groups

Case Studies

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LTCOP Role in HCBS

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Population Served

Nursing Homes, Board and Care Homes (Assisted Living and Similar Facilities)

Federally-mandated population: long-term care facility residents

OAA requires LTCOP to serve individuals who reside in long-term care facilities—defined as:

Nursing facilities 

Board and care homes

Any other adult care home, including an assisted living facility, similar to a nursing facility or board and care facility 

[OAA, Sec. 102(35), Sec. 712]

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Population Served

In-Home Services

17 State Ombudsmen reported that their programs have the authority to serve individuals who receive long-term care services in their own homes. 

Because the OAA does not authorize the LTCOP to serve individuals who receive serves in their own homes, federal OAA funds cannot be used to serve this population. States use state funds or other sources of funding to serve in-home consumers. 

As revised in 2016, the OAA authorizes LTCOPs to serve residents who are transitioning from a long-term care facility to a home-care setting “when feasible.” 

Sources: SLTCO Survey; OAA Sec. 712(a)(3)(I)

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Number of Facilities Served

Data: NORS, 2016 
| 2016                  | Licensed Facilities | Beds         | Beds Per Facility |
|-----------------------|---------------------|--------------|-------------------|
| Board and care homes* | 59,189              | 1.37 million | 23                |
| Nursing facilities    | 16,372              | 1.71 million | 104               |

Over three times more board and care/assisted living facilities compared to nursing facilities but fewer beds per facility

Fewer board and care/assisted living facility beds overall, but the gap has been narrowing over time

Nursing facility beds decreased by 2% from 2007 to 2016, while board and care/assisted living facility beds increased by 23% 

*Includes board and care, assisted living, and similar facilities, only those covered by the LTCOP as required by the OAA 

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Responsibilities

LTCOPs have the same responsibilities in board and care/assisted living facilities as in nursing facilities

In some states staff serve all settings, while others have staff dedicated to HCBS settings

Regulations governing HCBS settings vary across states. The level of regulation of these settings can impact the ability of Ombudsmen to advocate on behalf of residents

Federal HCBS settings regulations issued in 2014 are being phased in with full compliance required by March 17, 2022. These regulations impact settings that serve Medicaid beneficiaries.

Some board and care/similar homes are unlicensed.

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How do LTCOPs serve HCBS consumers and what are the strengths and challenges?

Findings from Interviews and Survey of State Long-Term Care Ombudsmen and NORS data

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Visits to Board and Care/Assisted Living Facilities

Data: SLTCO Survey 

State LTCOPs visit board and care/assisted living facilities routinely and/or in response to a complaint 

Half of states visit most or all board and care/assisted living facilities at least quarterly (on average)

Average frequency of visits made to most or all board and care homes by statewide program 
| -            | Frequency (# of states) | Percent |
|--------------|-------------------------|---------|
| Monthly      | 9                       | 17%     |
| Quarterly    | 20                      | 38%     |
| Twice a year | 4                       | 8%      |
| Annually     | 6                       | 12%     |
| Other        | 13                      | 25%     |

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Visits to Board and Care/Assisted Living Facilities

Data: SLTCO Survey (2018), NORS (2015)

On average, State Ombudsmen do not visit board and care/assisted living facilities as frequently as nursing facilities.
| Facility types and data sources                                     | Nursing Homes -Survey | Nursing Homes - NORS* | Board and Care Homes - Survey | Board and Care Homes - NORS* |
|---------------------------------------------------------------------|-----------------------|-----------------------|-------------------------------|------------------------------|
| Have Statewide goals                                                | 88%                   | --                    | 83%                           | --                           |
| Goals are at least quarterly                                        | 79%                   | --                    | 61%                           | --                           |
| Goals include visits in response to a complaint                     | 27%                   | --                    | 26%                           | --                           |
| Ability to visit most or all homes on a quarterly basis, on average | 79%                   | 67.5%                 | 56%                           | 27.5%                        |

*For the NORS data, percent of facilities visited at least quarterly, not in response to a complaint 

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Visits to HCBS Settings - Challenges

Data: SLTCO Interviews/Survey

Program Capacity: Regular facility visits limited in many states due to lack of resources 

Many programs struggle to visit all board and care/assisted living facilities quarterly and to conduct non-complaint-related visits. Barriers to regular visits include staffing, and distance of facilities.

In some cases, State Ombudsmen reported prioritizing some facility types over others given limited resources, such as visiting nursing homes more frequently than assisted living facilities.

67% of State Ombudsmen reported that regular board and care/assisted living facility visits not carried out as fully as they would like due to a lack of resources. 50% of State Ombudsmen reported this for nursing home visits.

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Resolving Complaints in Board and Care/Assisted Living Facilities

Data: SLTCO Survey

State Long-Term Care Ombudsmen were asked about complaint resolution in board and care/assisted living facilities:

most effective at resolving: “Autonomy, choice, preference, exercise of rights, privacy” - 54%

most challenging to resolve: “Admission, transfer, discharge, eviction” –  40%

takes up most of program’s time: “Admission, transfer, discharge, eviction” AND “Autonomy, choice, preference, exercise of rights, privacy”– each 31%

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Types of Complaints – Board and Care/Assisted Living Facilities

Data: SLTCO Survey
| Broad Complaint Categories                                       | NORS 2016 | Most Effective | Most Challenging | Takes up Most Time |
|------------------------------------------------------------------|-----------|----------------|------------------|--------------------|
| Care                                                             | 18%       | 12%            | 13%              | 15%                |
| Environment                                                      | 13%       | 0%             | 0%               | 2%                 |
| Autonomy, choice, preference, exercise of rights, privacy        | 11%       | 54%            | 8%               | 31%                |
| Abuse, gross neglect, exploitation                               | 8%        | 2%             | 4%               | 6%                 |
| Dietary                                                          | 7%        | 4%             | 0%               | 2%                 |
| Admission, transfer, discharge, eviction                         | 6%        | 8%             | 40%              | 31%                |
| Activities and social services                                   | 6%        | 4%             | 0%               | 0%                 |
| Staffing                                                         | 5%        | 0%             | 12%              | 0%                 |
| Policies, procedures, attitudes, resources                       | 4%        | 4%             | 19%              | 8%                 |
| Access to information by resident or resident’s representative   | 3%        | 10%            | 0%               | 0%                 |

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Regulations – Board and Care/Assisted Living Facilities

Data: SLTCO Survey

Almost one-fifth of State Ombudsmen report that “Policies, Procedures, Attitudes, Resources” is the most challenging type of complaint (second highest complaint category)

Sufficiency of board and care regulations to advocate for residents:

43% report guidance is sufficient

45% report guidance is a mix, depending on the type or size of the setting

12% report that guidance is not sufficient

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LTCOP Relationships with Facilities/Providers

Data: SLTCO Survey

When asked about the effectiveness of their statewide program’s relationship with HCBS providers, most Ombudsmen reported that either a majority or some relationships are effective.
| -                                   | Board and Care(N=51)* | In-Home(N=16)** |
|-------------------------------------|-----------------------|-----------------|
| Majority of relationships effective | 39%                   | 25%             |
| Some relationships effective        | 49%                   | 56%             |
| A few relationships effective       | 12%                   | 19%             |
| No relationships effective          | 0%                    | 0%              |

*Missing=1; **Missing=1

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LTCOP Relationships with Facilities/Providers

Data: SLTCO Survey, Interviews

State Ombudsmen reported more effective relationships with nursing homes compared to board and care facilities and compared to in-home care providers 
| -                                   | Nursing Homes(N=51)* | Board and Care Homes(N=51)** | In-Home Providers(N=16)*** |
|-------------------------------------|----------------------|------------------------------|----------------------------|
| Majority of relationships effective | 51%                  | 39%                          | 25%                        |
| Some relationships effective        | 47%                  | 49%                          | 56%                        |
| A few relationships effective       | 2%                   | 12%                          | 19%                        |
| No relationships effective          | 0%                   | 0%                           | 0%                         |

*Missing=1; **Missing=1; ***Missing=1

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Successful practices

Data: SLTCO Interviews

Strong relationship with licensing and survey agency

In one state, some board and care homes have been found to be operating illegally without a license. The LTCOP meets regularly with the survey agency about issues related to these homes, including the relocation process when homes must be closed. In addition, the agency attends the LTCOP annual statewide training and shares facility trends.

Mental health training 

One LTCOP works closely with the state mental health agency on training for Ombudsman staff and advocating for mental health training for staff in residential care facilities where staff have limited knowledge of these issues.

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Sources

NORC Survey of State Long-Term Care Ombudsmen (SLTCO) (2018)

NORC interviews with SLTCO (2017)

National Ombudsman Reporting System (NORS) data (2016)

The National Long-Term Care Ombudsman Resource Center, “State Funding Support for Assisted Living Facilities” (July 2014). 

Greene, Lepore, et al. ASPE. “Understanding Unlicensed Care Homes: Final Report” (September 2015).

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Thank you

Kim Nguyen, PhD	

301-634-9495

nguyen-kim@norc.org 

Sarah Downie			

301-634-9304

downie-sarah@norc.org

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