BP - HI Expansion

2006 Annual State Ombudsman Training Conference
Success in Ombudsman Programs

Justification to Expand LTCOP to Neighbor Islands

Hawaii

Category: Program Management

Project Description: 

Currently Hawaii has 8,606 long term care residents living in licensed nursing homes, adult residential care homes, expanded adult residential care homes and assisted living facilities.  All projections indicate that, with the baby-boomers rapidly approaching age 65, that number will rise dramatically.  Since traditional nursing homes are so expensive to build, staff and maintain, there will most likely not be an increase in these facilities but rather an increase in care home and assisted living beds, as well as other options not yet fully developed or available (such as assisted living facilities for Medicaid recipients).   In addition the need for foster home beds (RACCP homes) will also increase and probably become "licensed" instead of "certified," which is the current practice. That means foster homes will also come under our jurisdiction.  This increase, spread throughout all the Neighbor Islands and Oahu, in smaller congregate/community sites rather than the traditional nursing home, will place additional burdens on the LTCOP....burdens which the present LTCOP can not meet without additional funding and staffing. 

In a growing number of states, with appropriate funding from their state legislatures, the LTCOP has also begun expanding their advocacy and services into other areas where there are increasing unmet needs.  Who advocates for the senior in a hospital or other acute care setting prior to admission to a long term care facility? No one. Who advocates for someone discharged home and having problems with their home health agency? No one.  Who advocates for someone still in a hospital, not because they are still needing acute care but rather because there are no nursing home beds available, or because no one wants a resident with Alzheimer's or some other cognitive/behavioral deficit? No one. Who advocates for someone in prison and now a senior - frail, no danger to society anymore and now easily preyed upon by younger, stronger inmates? No one.  Who advocates for the growing number of homeless seniors (especially during this hot real estate market!) trying to survive alone on the streets? No one.  This is only a partial list of unmet needs which could be addressed by the LTCOP with additional funding and staffing.

The Institute on Medicine's 1995 report "Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act" recommends that at a minimum, states should have one full time paid LTC ombudsman per every 2,000 residents. Hawaii has only 2 LTC ombudsmen for 8,606 residents.  That's less than half the minimum staffing recommendation. We can do better.  Our program's operating budget is only $13,000.  That calculates to $1.51 per resident.  The Older Americans Act of 1965 mandates that the LTCOP provide "regular and timely access" to all 8,606 long term care residents.  With our current staffing and budget, that mandate is impossible to meet and places us out of compliance.

What we would like to recommend is that the State Legislature provide the additional funding for a full-time Kauai LTC Ombudsman, a full-time Maui LTC Ombudsman and a full-time Hawaii (Big Island) LTC Ombudsman.  These three additional positions would be State workers housed (hopefully but not necessarily) in the three county Area Agencies on Aging offices or within a Department of Health office. The current State LTC Ombudsman Specialist (Anne Holton) would assume the title of Oahu LTC Ombudsman - which is really what she does anyway so that would not be a change. The total cost for these three additional positions would be (XXX) dollars.

How will this expansion and additional cost benefit the people of Hawaii? A "local" ombudsman already knows their island, resources, contacts and, most importantly, the people better than someone coming from Honolulu. A local ombudsman can investigate complaints and concerns quicker and cheaper (no airfare, car rental, hotel or per diems needed), especially in the smaller care homes. A local ombudsman has greater access to local county officials, legislators, press and media, community and senior groups, churches, etc. A local ombudsman knows where to go for volunteers and can supervise them more easily than someone coming from Honolulu. And a local ombudsman could be available to meet the public at the proposed counties Aging and Disability Resource Centers. This proposed model would not replace the current State model but rather enhance it.

The State LTC Ombudsman by federal mandate is the only one who can "certify" an ombudsman, which is a requirement.  The State LTC Ombudsman would be responsible for the hiring and firing (with the State Unit Director on Aging), training and supervision of these 4 local ombudsmen.  The State LTC Ombudsman would provide continuing education and technical support and would be available to investigate more complex cases. The State LTC Ombudsman would be available for consultation, problem solving, brain-storming and could also be the back-up for the ombudsmen volunteers when the local ombudsman is sick, on vacation or not available due to jury duty, family leave, etc. Under this model, the State LTC Ombudsman could also have the necessary time to develop other models for expansion of the program into new areas [mentioned above] with collaboration from other State and County Agencies, legislators and the public.   Our program could be more pro-active in preventing abuse, neglect and exploitation of our kupuna and more involved in social policy development.

Our LTCO Volunteer Coordinator could continue providing the training to ALL State LTCO volunteers but the local ombudsman would do the recruiting and screening on their respective islands - more time efficient and cost effective.  There will always be turnover with this type of intensive volunteer opportunity. Many people are not comfortable visiting sick seniors or trying to carry on a conversation with residents who suffer cognitive loss, speech impediments, various types of disfigurements or other limitations, etc. We appreciate our volunteers very much but there will never be enough of them to visit all 731+ facilities on a "timely and regular" basis, as mandated by state and federal law. Our kupuna cannot, and should not be expected to wait for the kindness of strangers to assist as their advocates.  Our LTC senior population is getting older, sicker and more vulnerable.  Many have children and other family members who have moved to the Mainland or another island. Some have even outlived their children. They have to fend for themselves and some just can't do it anymore. The need for advocates is greater than ever and will continue to increase.

We also ask that the Legislature restore our clerical position, which was taken away last year.  Running a large volunteer program requires much time lining up speaking engagements, arranging for rooms and refreshments, assembling training materials, sending out letters, parking passes, updating information, collecting data for mandatory State and Federal reports, etc. All of these "clerical" tasks are important and necessary but it means less time for the Volunteer Coordinator to meet face-to-face potential volunteers, speak at the AARP chapters, rotary clubs, churches, etc

If it is not possible to get the necessary funding and legislative support for the 3 additional local ombudsmen, we still believe restoring the clerical position is vitally important if we are to reach our goal of creating and maintaining a strong and vibrant LTC Volunteer Ombudsman Program on every island.  Total cost for this position would be (XXX) dollars. This was money already approved by the full Legislature in 1999 before the surplus. For too long Oahu has reaped most of the benefits of our programs' state and federal dollars while the Neighbor Islands have gone without.  Make no mistake, the LTCOP has been able to respond to every complaint and we continue to meet with Resident and Family Councils and provide staff in-services on all the Neighbor Islands but we know we can do more, much more with that clerical position re-instated, additional volunteer ombudsmen on every island and a small increase in our program budget.  As mentioned above, we have roughly $1.51 per senior.  If we could increase that to just $5.00 per senior, it would only cost the State an additional $30,030.  Total operating budget would then be $43,030 if the LTC resident’s population remains at 8,606. With the present budget we have no money for PSAs on the radio or TV stations, no money for signs placed on city buses or newspapers, etc. Increasing our program's visibility and recruiting additional volunteers is made more difficult when we are constantly forced to beg for the smallest assistance.

The State LTC Ombudsman + 4 "local" ombudsmen + 1 Volunteer Coordinator + 1 clerical support staff is the best model for meeting the current and projected needs of our LTC residential population and we ask that you give this serious consideration. If this is not possible, then we ask that you at least increase our operating budget to $5 per resident ($43,030) and restore our clerical support staff.
Mahalo.

Unlike many other states that are over-bedded for institutionalized long term care, Hawaii is under-bedded, and the State is seeking ways to prepare for projected increases in demands for licensed care beds statewide.  The EOA’s Long Term Care Ombudsman program, established by the Older Americans Act, is staffed by two qualified Ombudsman specialists who are charged with assuring advocacy and patient rights protection for an estimated 8,000 residents of 731 licensed facilities in Hawaii.  In recent years, the Legislature provided $90,000 for the recruitment, training and sustaining of volunteers to augment the Ombudsman staff and assure Neighbor Island coverage.  This has not proven an adequate or feasible solution to assuring services for all licensed facility residents, many of whom do not have family members to assure their maximum care in an institutional setting.  In 2005, the Legislature deleted the State-funded clerical position that supports the volunteer program, confidential database maintenance, and required program reporting.  State funding presently averages $1.51 per facility resident, and travel costs for the Oahu Ombudsman staff are limiting both Ombudsman and volunteer capacities.

The EOA requests funds to establish Ombudsman specialist positions for Kauai, Maui and Hawaii Counties, Clerk Typist II position in EOA and operating costs to support the Neighbor Island Ombudsman and volunteer programs.

Personnel Costs
3 Program Specialist IV, SR 22                                                           118,008   118,008
1 Clerk Typist II, SR 08                                                                          24,792     24,792
                                                                                          Subtotal       142,800   142,800

Fringe 34.44%                                                                                         49,180     49,180 

                SUB TOTAL: PERSONNEL                                                 191,980   191,980

Other Current Expenditures                                                                 100,000   100,000

Equipment                                                                                                        50,000

                TOTAL                                                  341,980   3291,980

COST ANALYSIS for LTCOP Neighbor Islands Expansion

Kauai:

5 Nursing Facilities
16 Adult Residential Care Homes (73)
1 Expanded Adult Residential Care Home (2)
1 Assisted Living Facility (100)
TOTAL: 23 

Molokai:

1 Nursing Facility
4 Adult Residential Care Homes (31)
1 Expanded Adult Residential Care Home (3)
TOTAL: 6 

Lanai:

1 Nursing Facility
TOTAL: 1 

Maui:

4 Nursing Facilities
13 Adult Residential Care Homes (61)
1 Expanded Adult Residential Care Home (2)
1 Assisted Living Facility (144)
TOTAL: 19 

Hawaii (Big Island):

8 Nursing Facilities
48 Adult Residential Care Homes (211)
14 Expanded Adult Residential Care Homes (28)
1 Assisted Living Facility (220)
TOTAL: 71

GRAND TOTAL: 120

1. The Long Term Care Ombudsman is mandated by the Older Americans Act of 1965 to respond to complaints made by or on behalf of long term care residents.  It's hard to predict in advance how many complaints from the Neighbor Islands might require a visit by the Long Term Care Ombudsman to a nursing home, adult residential care home, expanded ARCH or assisted living facility. Certainly the more visible our program becomes to residents, families, staff and the general public, the more complaints are reported to our office. If we were to conservatively estimate two complaints a week from any of the 4 types of facilities, that would be 104/yr x 5 islands x $293 totals $152,360 per year.

As of today (Feb.13, 2006), airfare on Hawaiian Airlines for a Neighbor Island is between $146 to $196 roundtrip plus tax (approximately $20), depending on flight time and availability. The car rental with Thrifty is approximately $40.  The per diem for meals is $20.  Airport parking is $10/day. Mileage (18 miles roundtrip) for gas from my home to the airport is currently $ 7.00. 

Total per trip $293.00

2. Sometimes a complaint being investigated may require that the Long Term Care Ombudsman spend the night at a hotel.  This could be because the complaint involves the night shift or early morning shift when flight times would make it impossible to commute and investigate as needed.  According to Panda Travel, a one night hotel room for a state worker is approximately $ 100.  If we calculated that this might happen once a month per Neighbor Island, that would be 5 islands x $100 for a total of $500 per month or $6000 per year. 

NOTE: This number is low, not accurate in that an overnight visit would increase the cost of Honolulu airport parking to $20 and the meal per diem would also increase.

(Kauai has 4 state approved hotels with an average of $95.84/night, Maui has 3 state approved hotels with an average of $101.38/night and Hawaii has 5 state approved hotels with an average of $77.94/night.  That average is pulled down because one hotel in Hilo is only $44.35.  I included Hilo and Kona together.)

3. The Long Term Care Ombudsman is mandated to ensure all long term care residents have "timely and regular access" to the Long Term Care Ombudsman Program. According to the U.S. Administration on Aging, the expectation is that we visit every resident at least once every 6 months. Routine visits to these facilities provides visibility for the program, allows the residents, family members, staff and administrators to establish a relationship with the ombudsman, voice concerns and complaints and access other services provided. Being pro-active also reduces serious complaints and incidents of abuse, neglect and exploitation. 120 facilities x 2 (every 6 months) x $293 totals $70,320 per year.

 4. The Long Term Care Ombudsman is mandated to meet with facility Resident Councils at least once a year.  On the Neighbor Islands we have 19 nursing homes plus 3 assisted living facilities with Resident Councils. We might be able to combine two facilities on the same visit. 11 x $293 totals $3,223 per year.

5. The Long Term Care Ombudsman is mandated to meet with facility Family Councils at least once a year. (Many Family Councils met in the evenings or weekends when family members are not at work. This complicates our visits from Honolulu.)  We have 19 nursing homes plus 3 assisted living facilities with Family Councils. 22 facilities x $293 totals $6,446 per year.

6. Our federal mandate requires that we "facilitate public comment on the laws, regulations, policies and actions," "promote the development of citizen organizations," and educate the public on issues affecting the health, safety, welfare and rights of our Long Term Care residents. We do community outreach, participate in Senior Fairs, talk to college students, retiree organizations, other state and county staff, etc.  If we did only one community education presentation per month per Neighbor Island, that would be 5 islands x $293 totals $1,465 per month or $17,580 per year.

7. Facility staff in-services are also part of the Long Term Care Ombudsman Program’s federal and state mandate.  Our office provides in-services on our program, Residents Rights, Elder Abuse and How to Prevent It, Dealing with Difficult Residents, End-of-Life Issues, Advance Directives, etc.  If we were to provide 2 in-services per year to every facility, that would total 120 facilities x 2 in-services/yr. x $293 or $70,320 per year.

8. Training for certification of our Long Term Care Ombudsman Representative Volunteers requires 28 hours. 20 hours of classroom training are spread over 5 days (4 hours each day is all our senior volunteers can handle) plus 2 on-site training sessions, again 4 hours each, with a grand total of 28 hours for certification.  If we did quarterly training on all 5 islands for recruiting new volunteers, that would be 7 days x 5 islands x $293 totals $10,255 per quarter or $41,020 per year. 

NOTE: This isn't completely accurate because the last two days of on-site trainings are "individual" sessions with only the volunteer assigned to that particular facility. The more volunteers we have, the more time required to train and greater the cost. In the above example, we would only be training one volunteer per island per quarter.  Our classes are usually 5 students per class. For the on-site training, that would more likely be 5 volunteers x 5 islands x 2 visits x $293 totals $14,650 per quarter or $58,600 per year.

At this time we don't know if we could get a free conference room for these trainings at a Department of Health office or a county Office on Ageing conference room. We might have to rent the space.  We generally provide simple refreshments which we would buy there rather than carry on the plane since we have all the training materials to carry.  We use videos with our trainings so we would also need a TV and VCR.  We are also putting the materials on PowerPoint so would need to carry the laptop and projector.  It's a lot of stuff to carry from island to island.

9. All our volunteers are expected to attend our monthly meetings for continuing education, support, and sharing with one another of what's happening at each facility.  Since we couldn't afford to fly all our volunteers to Oahu, we would have to go to their islands.  That would be 5 islands x $293 totals $1,465 per month or $17,580 per year.

10.  All volunteers are evaluated quarterly.  As the number of volunteers grows, this will become more expensive.  Because we have 731 facilities, our long term goal is 731 volunteers.  All would need to be evaluated.  If we don't count the facilities on Oahu, the total number of volunteers on the Neighbor Islands could be 120.  If we were able to evaluate 2 a day at their assigned facility, that would be 60 x $293 totals $17,580 per quarter or $70,320 per year.

11. Recruitment of volunteers doesn’t happen by itself.  It requires presentations to various senior advocacy groups, rotary clubs, AARP chapters, contact with the local media, etc.  To replace volunteers who move on after they complete their 1 year commitment with our program can be very time-consuming.  If we did just one presentation for recruiting volunteers a month, that would be 5 islands x 12 months x $293 totals $17,580 per year.

The above is only a MINIMUM to meet our federal and state mandate. We are only talking logistical/transportation-related costs. We could do much more pro-actively with a Long Term Care Ombudsman living in each county, getting to know the residents and their families, the local media, local organizations and clubs, local legislators, local “movers and shakers,” fundraising, etc.  The Neighbor Islands deserve the same "timely and regular access" to the Long Term Care Ombudsman Program services as Honolulu.  This is an idea whose time has come.

$152,360

$6000

$70,320

$3,223

$6,446

$17,580

$70,320

$41,020

$17,580

$70,320 

$17,580

FINAL TOTAL: $472,749/year

Project Impact:

Meet our federal mandate FINALLY and COMPLETELY.  More visibility. Quicker response. Preventative action.  Residents will get better care. Staff will be better trained because we can then identify weaknesses and design in-services specific to those problem areas. Family members and residents will feel more empowered to speak up and demand better care.

Contact Person: John G. McDermott

Phone Number: (808) 586-7268     Fax: (808) 586-0185     E-mail: john.mcdermott@doh.hawaii.gov