It’s early afternoon when you’re sent to a local dialysis center to pick up 84-year-old Mr. Simms. As you transport him back to Shady Groves, his skilled nursing facility, he bends your ear with complaints about his care. The staff at Shady Groves are rough and negligent, he is frequently shuffled between rooms or floors, many times he waits 20 minutes before they answer his call bell, and they routinely send him to appointments and the hospital without his input or even his knowledge. You listen sympathetically, but feel powerless to help; his problems go beyond your scope. What’s worse, this is far from the first time you’ve had a similar experience, and you wonder if there’s a better way to assist patients like Mr. Simms.
Patient advocacy is one of the central responsibilities of any EMS provider. Particularly on non-emergent calls, such as minor complaints or transfers to scheduled appointments, our medical responsibilities are often minimal, and we have more time to seek out other ways to help our patients. For residents of long-term care facilities, this often means acting as go-between or problem-solver for complaints about their daily care or living conditions. Unfortunately, our desire to help often exceeds our practical capacity—we typically lack the expertise to successfully “work the system” in their favor, and even if we could, raising too much fuss can antagonize contracted facilities, which could mean a short trip to the unemployment line. Theoretically, these battles should be fought by the patient’s family members or medical proxy, but such people often don’t exist or are only minimally involved.
The ideal solution would be an outside party—someone we could call in to act on behalf of patients when we no longer can. It would be someone with the knowledge to help successfully, the independence to act freely, and the desire to advocate tirelessly for individuals who are unable to do so themselves. Fortunately, this person actually exists, and they’re just a phone call away. They’re called the long-term care ombudsman, and there’s one in your area.
The Ombudsman Program
The Long-Term Care Ombudsman program was born out of the federal Older Americans Act of 1965, evolving over the years until an amendment in 1978 made the program universal. In brief, it’s a federal mandate that each U.S. state create a system to serve elderly residents of long-term care facilities by collecting statistics, promoting large-scale reform, training nursing staff on common problems, and most of all by assisting with specific complaints. The law requires and funds certain basic provisions, but within those constraints states are free to implement them in unique ways or to add additional measures.
In most states the program is managed under a Unit on Aging, or similar department. Typically, it consists of several full-time staff overseeing a larger number of trained volunteers. Most centralized activities, such as assembling data to present to the federal Administration on Aging, are managed at the state level; however, there’s often a network of local offices to handle actual casework. In my own Massachusetts, for instance, there are 24 regional ombudsman branches, each operating out of a local non-profit agency that provides various elder service services. (By law, the state can subcontract with agencies like this, but they must be free from conflicts of responsibility, such as any commercial ties to area facilities.)
Referrals and complaints can come directly from patients, but also from other parties, such as family, hospital staff or even emergency personnel—that’s us. In addition, some states, such as Massachusetts, practice rounding, visiting regularly with the residents in each facility to touch base and establish a relationship. This can help resolve disputes before they escalate.
The ombudsman program serves all residents in licensed long-term care facilities. This includes skilled nursing homes, assisted living centers and board-and-care homes. They will act on behalf of any resident, including short-term rehab patients who are co-located in long-term facilities.
How Ombudsmen Can Help
How can you recruit this system to help your patients?
Start by finding the phone number. The law requires that all long-term facilities post contact information for the relevant ombudsman in a public area, although some places manage to hide it pretty well. If so, an Internet search can often help.
Give them a call and provide, at a minimum, the resident’s name, their home facility and a description of the complaint. Your name and contact information would also be helpful. Within 24 hours for life-threatening complaints, and otherwise “as soon as reasonably possible,” a representative of the ombudsman will visit the patient to discuss the matter. With permission from the patient or the patient’s proxy or guardian, they can review any patient records or documentation; if they believe the guardian is not acting in the patient’s best interest, it’s also possible to bypass such permission. Facility staff must provide the ombudsman with access to patients, charts and the facility, and must not willfully interfere with investigations. For their part, ombudsmen must be free from conflicts of interest, including Adult Protective Services responsibilities (and are not permitted to act as a proxy or surrogate for individual patients), and in turn have some immunity from prosecution due to execution of their duties.
Although you can report complaints anonymously, this can make it difficult for the ombudsman to follow up with you if additional details are needed. It’s reasonable to be concerned about sticking your neck out but the law requires the ombudsman to respect your confidentiality, in some cases even where a legal requirement for reporting exists (such as elder abuse). Without a court order or your explicit consent, your name will not be released. It’s also illegal for staff to retaliate against you, the patient or anybody else for their involvement in an investigation.
What powers do ombudsman’s representatives wield? They are not police, and do not function in an enforcement capacity. Beyond the protections we just described, they have no independent authority as regulators. But they are intimately familiar with the rights of residents and their various avenues of recourse. They know the phone numbers and which doors to knock on, which names to drop and how to make things happen. They have legal advice and representation on-call. They do maintain close relationships with agencies like the Department of Public Health, and if necessary will involve them in criminal cases, such as those revealing actual abuse or gross negligence. Most complaints, however, involve hygiene care, staff attitudes, environmental disrepair and other issues we’re all familiar with. Thus, their main tools are negotiation and mediation, along with perseverance and the explicit, single-minded mission of fighting for those who need a champion.
Does it work? I’ve invoked the ombudsman for half a dozen patients, and while it hasn’t always achieved exactly what I wanted, I feel they’ve always given it the best possible chance. According to the national statistics, each year around 75% of complaints are resolved satisfactorily.
And compared to some of our interventions, that’s not bad at all.
Thanks to the Massachusetts Executive Office of Elder Affairs for its assistance with this piece.
Brandon Oto, BA, NREMT-B, is a field EMT and PA student from the New England area, as well as editor of EMSBasics.com and LitWhisperers.com. His interests include BLS fundamentals, evidence-based medicine, ECG interpretation, and cardiac arrest care.