Ombudsmen a Plus for Quality Care

by Gretchen Henkel

Ombudsmen--whose charge is to serve as LTC patient advocates--are primarily known by LTC providers in their roles as investigators of complaints of abuse and neglect. Today, all LTC facilities (including skilled nursing, assisted living, and adult day services facilities) are required to give incoming residents contact information for their local ombudsman offices, which operate under the aegis of state agencies on aging.

But ombudsmen should not be viewed as adversaries, say Jonathan M. Evans, MD, CMD, an Associate Professor of Medicine and Chief of Geriatric Medicine in the Division of General Medicine, Geriatrics and Palliative Care at the University of Virginia Health System in Charlottesville and Andrew N. Dentino, MD, Chief of the Section of Geriatrics and Director, Program in Medical Ethics at Louisiana State University Health Sciences Center-Shreveport. The geriatricians noted in a session at AMDA's annual symposium in March that by accessing the conflict-resolution and technical-support skills that are core to the Ombudsman Program, facilities can more effectively act in the best interests of their residents. In addition, forming alliances with local and state ombudsmen can also improve a facility's visibility and enhance its image in the community.

A "Bad Rap"

These positive effects of increased dialogue with ombudsmen must be carefully cultivated, noted Dr. Evans, who is also a member of Caring's Editorial Board. He acknowledged that this may not be an easy task.

"Part of the reason ombudsmen get such a 'bad rap' is that they are involved in investigating complaints," Dr. Evans said recently from his office in Charlottesville. "Many facilities have been on the receiving end of inquiries from an ombudsman, when someone has complained [about unsafe conditions, bedsores, etc.] and the ombudsman has taken an adversarial approach." In the current "enforcement environment," he explained, providers often feel that the criticisms leveled against them by state surveyors are unfair. "As a consequence, people view government and quasi-government agents [such as ombudsmen] somewhat negatively."

Yet, ombudsmen comprise "a community resource of trained and available people who have some skills in conflict resolution," Dr. Evans continued. "Therefore, the nursing home should consider them as allies," and the facility's medical director should cultivate a good working relationship with the ombudsmen in his or her area. "The medical director should meet the ombudsmen, find out their concerns about a facility or an area, and ascertain their background and training, as well as their personal strengths or interests."

Fostering Communication

Dr. Dentino has helped to foster communication between LTC providers and state and local ombudsmen in the geriatrics department of LSU's School of Medicine. The university has taken an informal "Q&A" approach, said Dr. Dentino. When an ombudsman has a question about LTC care, he or she is encouraged to call the department. For instance, one ombudsman called to report that a physician did not seem to be addressing his patient's falling albumin levels, and wanted to know whether this constituted neglect.

The ombudsman's office reciprocates when LSU faculty or residents have clarification questions regarding policy or residents' rights.

For a number of years, Dr. Dentino has been lecturing at the Louisiana State Ombudsman Conference, where he addresses a topic--usually involving ethics, patients' rights, or clinical issues such as pain management--selected by the organization.

"I find these conferences refreshing," he said. "The ombudsmen are usually keenly and honestly searching for some help with issues in which the geriatrician is considered to be an expert. I get to meet the new ombudsmen and touch base with more senior ones, and I use this opportunity to clearly state my offering to serve as a resource for them throughout the year."

Dr. Dentino has also invited ombudsmen to lecture and conduct grand rounds with students and trainees at the medical school. The ombudsmen might also encounter the same trainees at a nursing home during their clinical rotations, and the fact that they lecture at the medical school give them "an elevated stature" among the trainees. Dr. Dentino has seen this practice "successfully spawn relationships, projects, and ideas--not just academic research, but community-advocacy projects as well." For example, one ombudsman suggested to a group of nurse trainees that they bring in Dr. Dentino to present educational lectures on elder abuse, and then develop procedures on how to identify this problem.

Dr. Evans has found ombudsmen especially helpful for mediating among family members who disagree over end-of-life decisions for a close relative. "When there are problems, particularly family problems, then I see it as natural to involve the ombudsman to help sort out conflicts. In many respects, that is the easiest way to interact with the ombudsman, because the issue isn't the facility versus the resident. The issue is that the facility is trying to do the right thing without choosing sides. This is an opportunity [for an LTC provider] to take the initiative as an advocate [for the resident] and to potentially develop a professional relationship with the ombudsman."

Other Advantages

As part of its Nursing Home Quality Initiative (see "Cultural Change Key to Nursing Home Quality Initiative" in the March issue of Caring, p. 1, and "Making (Up) the Grade: What You Need to Know About Nursing Home 'Report Cards'" in the August issue, p. 3), the Department of Health and Human Services launched a joint initiative last May with its Administration on Aging and Centers for Medicare & Medicaid Services to tap the expertise of ombudsmen. The plan is for ombudsmen to work with CMS' Quality Improvement Organizations to respond more effectively to consumers' queries about the new CMS quality measures. Ombudsmen will use the comparative data on nursing homes ("Nursing Home Compare" at www.medicare.gov) to help families make more informed choices about placement for their elderly family members, as well as other LTC options. This initiative ties in with the core missions of the Ombudsman Program: to help residents and their families and friends understand and exercise rights that are guaranteed by law (www.aoa.gov/factsheets/ombudsman.html).

Working in partnership with ombudsmen can improve quality on several different levels, Dr. Evans asserted. These include:

• Solving problems for individual residents and family members
• Integrating the facility into the community
• Dealing with problems when they occur, instead of waiting until they become worse.

Dr. Dentino recalled summoning the local ombudsman after witnessing a very frail 97-year-old patient develop bruising from a spontaneous rotator cuff tear after a coughing episode. After stabilizing the patient's shoulder, Dr. Dentino called the family and the ombudsman. The facility's director of nursing and administrator were also involved in investigating the incident.

"All of these people had already met on more social terms," Dr. Dentino said, "and this was invaluable. They realized that I was not trying to 'pull the wool over their eyes'; I was merely describing what happened."

In building collaborative relationships with ombudsmen, it is helpful to remember that they are "ambassadors" for both the state and for the protection of patients, said Dr. Dentino.

"If 'ombudsfolk' are interested in quality, then that automatically means that we, as medical directors and other long-term care providers, need to have a relationship with them," Dr. Evans emphasized.

Medical journalist Gretchen Henkel is a Contributing Writer to Caring.

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