How the Long-Term Care Ombudsman Program Helps People Who Have Medicare

SUMMARY
As a contractor for Medicare, Kepro serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Kepro provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare. 

This episode is a conversation with our guest from the Oklahoma Long-Term Care Ombudsman, Bill Whited. He will talk about the services that their organization offers for Medicare beneficiaries.

Bill serves as the State Long-Term Care Ombudsman for the State of Oklahoma and is responsible for administering the Oklahoma’s Long-Term Care Ombudsman network and systems and legislative advocacy for Oklahoma’s long-term care residents. He has more than 25 years of experience in the development and delivery of aging, mental health, juvenile justice, and human services programs in Oklahoma. His background includes over two decades of service with the Oklahoma Department of Human Services, including service as an Adult Protective Services investigator before becoming a Long-Term Care Ombudsman in 2003.

For more information about Kepro BFCC-QIO, please visit www.keproqio.com.

KEY TOPICS
01:37: Overview, introduction of guest, Bill Whited
03:17: Introduction of Long-Term Care (LTC) Ombudsman Program.
07:00: Examples of when someone would contact the LTC Ombudsman Program.
11:01: How volunteers help staff the LTC Ombudsman Program.
16:30: More information about accessing Kepro’s services and podcasts.

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RESOURCES

BFCC-QIO Information for stakeholders: www.keproqio.com/partners

BFCC-QIO Information for people who have Medicare: www.keproqio.com/bene

Oklahoma Long-Term Care Ombudsman Program: https://oklahoma.gov/okdhs/services/cap/ombudsman.html

Find the Long-Term Care Ombudsman Program in your state: https://theconsumervoice.org/get_help

Information about the Long-Term Care Ombudsman program: https://acl.gov/programs/Protecting-Rights-and-Preventing-Abuse/Long-term-Care-Ombudsman-Program

Music: Motivational Upbeat Corporate by RinkevichMusic
https://soundcloud.com/rinkevichmusic
Video Link: https://youtu.be/U78mgVaM12M

Transcript

Nancy Jobe
Hello everyone and welcome to another edition of Kepro’s podcast, Aging Health Matters. My name is Nancy Jobe, an Outreach Specialist for Kepro, and I will be your host today.

Kepro is the Beneficiary and Family Centered Care Quality Improvement Organization, and we are a Medicare contractor, one of two. And keep Kepro holds 29 states as the Beneficiary and Family Centered Care Quality Improvement Organization. And what the BFCC QIO does is we have three key services to help Medicare beneficiaries, one of them being the right to appeal a hospital discharge, ask for an appeal for a skilled service termination, such as hospice, home health, skilled nursing, outpatient rehab. Any time a beneficiary is being discharged from those services, they have a right to appeal that, and they would do that through contacting Kepro. We also have one of our services of a quality of care complaints for a beneficiary if they have an issue with the provider and wish to file a quality of care complaint; they would do that by contacting Kepro.

And we also have an Immediate Advocacy service that is a service offered to Medicare beneficiaries should they be having any kind of medical questions, problems, issues with providers or just care. They have a right to contact us, and we try to advocate for them to get a good, healthy result for whatever issue they're having. You can find out more about this by checking on our website at keproqio.com, so if you want to find out more about the BFCC-QIO, please check keproqio.com.

Today we are going to be talking with our Long-Term Care Ombudsman partner to learn about their roles in helping Medicare beneficiaries. And as a reminder, we sometimes invite our partners to participate in our podcast based on the topic. And while we greatly appreciate their partnerships, we also want to be clear that their opinions and guidance expressed by them in this podcast is solely theirs or their agencies and are not necessarily those of Kepro, CMS, or the Medicare program. Please keep in mind that state by state guidance may differ as well.

Alright, I'm happy to have Bill Whited, the state Long-Term Care Ombudsman with the state of Oklahoma as our guest today, and we're going to talk with Bill to try and find out a little bit more about what Long-Term Care Ombudsman do for the Medicare beneficiary.

About let's first start with asking Bill a little bit about himself and how he became a state Long-Term Care Ombudsman; Bill?

William Whited
Thank you, Nancy. You know, it's been a long journey to get to where I am at as the state Long-Term Care Ombudsman. I've got 26 years of service in with the Oklahoma Department of Human Services. My anniversary was just a few days ago actually. And originally I started my career working with aged, blind, and disabled populations. I did some Adult Protective Services investigations for a while and then in 2003, I became a Long-Term Care Ombudsman.

And in 2014, I became the state Long-Term Care Ombudsman. So basically, I'm the program director for all of the state of Oklahoma on Ombudsman services, and we have really worked with all populations in long-term care facilities. But we especially work with those Medicare populations in a special way because they have special rules and special requirements. So we try to hook people up with the powers that be that can help them when they do run into problems in long-term care facilities, and Kepro is one of our great partners in doing so.

Nancy Jobe
 That's great, Bill. Tell us a little bit about the Long-Term Care Ombudsman program and how a beneficiary can access the services that are provided and what are the services provided.

William Whited
So the Long-Term Care Ombudsman program is an older Americans program. It came into existence in 1979, and we basically act as advocates for long-term care residents across the spectrum here in Oklahoma. In Oklahoma, we go into nursing homes and then a subset of nursing homes, which we refer to as ICFAIDS. That's an acronym, stands for intermediate care facilities for individuals with intellectual disabilities.

We also go into assisted living communities as well as residential care communities. We're not regulatory in nature, so we're there to be advocates. We explore when somebody's having problems or concerns, and we try to come up with resolutions to help them overcome whatever problem or concern that it is that they may have. So that's ultimately our goal is to be that advocacy voice. Here in Oklahoma, we've been really fortunate.

Since 1979, when the program came into the existence, we have only had two state ombudsman in our history of the program. My predecessor, Esther Hauser, was the state ombudsman before she retired in 2014 when I took over the realm at that point in time, and we have been very stable in our advocacy services across the spectrum. And so we don't just serve Medicare residents, we serve all residents regardless of their payor source.

Nancy Jobe
That's great. Bill. You mentioned that in the state of Oklahoma, this is how it works. Is the program pretty standard in most states, or do you do other states maybe offer something different or like does Oklahoma offer something different?

William Whited
You know, there are states that do some things a little bit different. Now we all have our standard federal rules that we’re required to follow, but in some states, Long-Term Care Ombudsman programs also go into home and community-based services. So they may go into home settings; you know here in Oklahoma, we have a program called Advantage Waiver, that is a long-term care waiver that helps people remain in the community, instead of going into institutionalized types of care settings.

And unfortunately, right now in the state of Oklahoma, we don't go into those settings, but we do work closely with Advantage members that may be receiving some care and assisted living homes across the spectrum. We have about a couple dozen homes here in Oklahoma that are referred to as what we call affordable assisted living. And that is where an Advantage member, if they do need assisted living type of care, they can actually go into one of these affordable assisted livings.

And they can receive some of their care needs met through the Advantage waiver program, where providers come into those assisted living facilities to provide those needs of the resident. And it's really a very unique arrangement. But as far as in home settings, Oklahoma doesn't go into in home settings, other states do. So you have to really reach out to your community partners in those other states. 

I encourage people to visit the consumer voice for quality long-term care website. They have a link and listing to every ombudsman program across the nation and you can click on the state that you're looking at, and you can learn the information about which states provide which services.

Nancy Jobe
Thank you for that information. Could you give us maybe an example of, kind of spell it out as far as like just say I was in a skilled nursing facility, and maybe an example of what kind of a reason why somebody would contact the Long-Term Care Ombudsman?

William Whited
So people can contact the Ombudsman for any concern that they may have. But one of our big complaint areas fall into three categories. One is transferring the discharge one or care concerns, and then the others are resident rights concerns. So residents that enter into long-term care facilities, they don't lose their rights. A lot of people think that when you go into an institutional setting, then you lose a lot of your rights. Not only do you not lose your rights, you gain additional rights.

And there are residents’ rights that are fortified in the Oklahoma Nursing Home Care Act as well as the Omnibus Reconciliation Act in 1987 that codify these additional rights in legislation. And so we work with the residents to empower them to have their own voice, to be their voice when they need a voice for them on their behalf, and to educate them about what their rights are.

Nancy Jobe
That sounds great, you know? And you're the advocate for that resident in that facility, and I understand the advocacy because I know Kepro has that program of Immediate Advocacy, and sometimes we get those phone calls for the skilled nursing facilities, and I know that we've even gotten them from the Long-Term Care Ombudsman when they're trying to advocate for a resident as well. So we understand the need and the importance of that beneficiary or resident to know that they have rights, and they're not just stuck there. So I'm really happy to have that Long-Term Care Ombudsman relationship, so that we can all work together to help those residents of those facilities.

William Whited
You know, Nancy, one of the things that I've really been thankful for over the course of my career is the relationship with Kepro that we have. And you know, we've worked mostly with Kepro over the years. And when we run into consumers that may need to file an appeal over a discharge, we refer them to Kepro and try to make sure that they get those advocacy services and that they know what their rights are.

And that's one of the things that is so difficult for many people is that they really don't always understand the system because the reality is that people don't always talk about long-term care ahead of time. You know, it's one of those issues that kind of reaches up and grabs you by the collar, so to speak, when you know your loved one ends up needing long-term care. So that's what the Ombudsman program is here for. We're here to help those consumers to help answer those questions, to get them contacted with the appropriate resources.

William Whited
And while we don't necessarily go into hospital settings, we get a lot of calls from hospital settings where a hospital may be trying to discharge a person who is on Medicare, and that beneficiary or their family may say, hey, wait, we're not quite ready for this. So we will educate them about the resources and services that Kepro provides and help them access those services.

Nancy Jobe
Yes. And that's why our partnership is so important, to be able to help these Medicare beneficiaries, for sure. Are you services free, Bill?

William Whited
Yes, they are, as Long-Term Care Ombudsman, we are not allowed to accept any kind of payment for the services that we provide. We are funded through the Older Americans Act, through some state dollars and some grants that we receive. Everything that we do is 100% free of charge to anybody that that we assist.

Nancy Jobe
Now does your program have a volunteer base to help with this? Because you have a lot of skilled nursing facilities and long-term care facilities and such in the state of Oklahoma and every state does. So what is the staffing for that?

William Whited
So right now in the state of Oklahoma, we have right around 600 long-term care facilities that we provide advocacy services in. And again, that spectrum is nursing home, assisted living, and residential care communities. And I have 27 field staff that are the Ombudsman supervisors across the state. And then we have a volunteer corps as well. And of course during COVID, our volunteer ranks got decimated. I mean people weren't allowed to go into nursing homes and long-term care communities.

For quite some time, the long-term care communities really got hit hard by COVID, and about 40% of the deaths across the country and here in Oklahoma occurred in long-term care communities. And so needless to say, that volunteer program took a big hit during COVID, and at one time, we had 214 volunteers across the state. Right now, I just ran the numbers the other day, we're running right around 45 volunteers across the state. So we need more.

So anybody who is listening to this podcast out there that is interested in becoming an Ombudsman, they can reach out to us; they can shoot us an e-mail at capcap.ombudsombuds@okdhs.org, and we can get you set up with training. Our volunteers are required to be properly trained and screened. So we do a national fingerprint background check to make sure that any volunteer that's coming into our program is appropriate to provide this services to our most vulnerable citizens across the state.

Nancy Jobe
And I would believe that that was probably true in every state. So whatever state  our listener is from, they should check that out with their state Long-Term care Ombudsman and their respective state and then maybe they would be able to help out and be a volunteer for that program there as well. So it's a wonderful opportunity to be able to help those people that are in these residential care facilities, to have an advocate for them while they're there because many of them don't even have family members or anyone to be able to help them. So your program is just wonderful for that.

William Whited
You know, Nancy, one of the things that I've always been trained on is that about 60% of residents have no regular visitor. So it's so important for the community to become involved in these long-term community settings and be out there, be the eyes, be the ears and the voice for those long-term care residents that sometimes need assistance. It's not always easy for somebody to navigate this. I mean,  let's face it, it's a huge system that's out there.

And many people across the spectrum just don't have any experience in that. And that's where an Ombudsman can help them. We will assist people with contacting multiple different agencies. We will investigate complaints and concerns for them, and we act as a clearinghouse of information. So if somebody is looking to find a long-term care community and you need some information, we have some wonderful resources that we share. We have a nursing home and alternative care handbook that we provide to our consumers across the spectrum here in Oklahoma.

And we can provide information about what types of complaints and deficiencies and or problems that a long-term care community has had, and so that way, a person can make an educated decision on where they may need to go for their long-term care services or where they may need to send their loved one for those services.

Nancy Jobe
That's great information. I think that the listeners, if they feel so inclined to find out more information about long-term care, but it's been in their state they should check out the consumerservice.org to get some information for their particular state, and of course, Bill would be your contact if you happen to be in Oklahoma as well.

But I think that this information has been very helpful and opening up the eyes for people to understand what you all do as a Long-Term Care Ombudsman and how you are such an important piece of the pie, so to speak, for the elderly or Medicare beneficiary as well to be able to have someone on their side and looking out for them a little bit more. Do you have anything else that you'd like to wrap it up with Bill?

William Whited
Well, first of all, I'd like to say thank you to Kepro because you guys do a wonderful job out there, and we've worked so closely over the years together. One thing that I do want consumers to know and understand about the Ombudsman program is we are a consumer-directed program. So we always see our residents any time there's a complaint or a concern. We do face-to-face visits with them. We include them in the process and trying to develop any type of resolutions that that may be implemented on their behalf. So it's not where we come in and make decisions on behalf of people.

We help them by empowering them to be their own voice and to actually participate in their own care planning and their own care needs as much as they possibly can.

Nancy Jobe
Thank you so much, Bill. I really appreciate you being our guest today and giving us some great information to move forward with learning about the Long-Term Care Ombudsman program.

Be sure and listen to our next podcast that will be coming up. We do a monthly podcast. You can find out more about Kepro’s podcast by going to keproqio.com, our website, to learn what podcasts that we have, and you can listen to any of the past podcasts that we've had. We've had many of them.

With respect to different Medicare beneficiaries and stakeholders that we work with, if you'd like to also receive a newsletter from Kepro, which we send out, you can sign up for that with the keproqio.com. So we look forward to having you listen to us and our future podcast. Any of the information that we have today will be available in the show notes. So please continue to listen to Aging Health Matters by Kepro.