RELOCATING NURSING HOME RESIDENTS in CLOSURES

1. RELOCATING NURSING HOME RESIDENTS in CLOSURES Tom La Duke; Relocation Ombudsman Specialist State of Wisconsin-Board on Aging and Long Term Care PO Box 180, Kenosha, WI 53141 (262) 654-4952 (phone) (262) 654-6194 (fax) Tom.Laduke@wisconsin.gov

2. Wisconsin’s Ombudsman Program Wisconsin statutes authorize the Ombudsman program to • Investigate complaints concerning improper conditions in long term care • Serve as mediator or advocate to resolve disputes • Promote public education to improve conditions • Monitor laws, regulations, and policies • Publish materials and initiate legislation to correct inadequacies

3. Wisconsin’s Ombudsman ProgramRegional Assignments PAULSOKOLOWSKI

4. Volunteer Ombudsmen Program • 90 volunteers in SNF’s in 3 regions of the State and 15 in select CBRF’s • Training-orientation and quarterly training • Responsibilities-weekly visit to assigned facility. Monthly written reports to a volunteer coordinator that shared with the assigned Regional Ombudsman

5. Wisconsin Statistics • 90 Nursing Home closures and/or down-sizings, since 1999 • Since the project began in March, 2006, there have been • 6 Nursing Home closures and • 1 Nursing Home down-sizing which have affected hundreds of residents who’ve had to relocate • 3 replacement relocations that involved the moving of another 350 residents as well as • Numerous down-sizing and closing of ICF’s-MR and CBRF’s

6. 3 Types of Relocation Activities in which a Nursing Home files a Plan in Wisconsin • CLOSURE- everyone must leave • DOWN-SIZING- some must leave • REPLACEMENT*- everyone must leave, but have a new place for everyone to move to.

7. Wisconsin State Statues require that a facility file a RELOCATION PLAN when: • The Facility is closing, intends to close or is changing its type or level of service or means of reimbursement and • Will relocate at least 5 or 5% of the residents whichever is greater

8. JOB DESCRIPTION • Title: Relocation Ombudsman Specialist • Status: Temporary Project Position (March, 2006-March, 2009) • Funding: Civil Money Penalties • GOAL: To advocate focusingon quality of Care and the protection of rights while residents relocate from closing nursing homes

9. JOB DESCRIPTION-continued • OBJECTIVES: • Inform, educate and assist residents and their families (develop informational materials and present to Resident and Family Councils) • Participate in Relocation Team meetings to represent the interests of the resident and promotepreferences for alternate placement • Participate in Discharge Planning Sessions as authorized Followup on residents after having relocated • Monitor closing facilities (communicate concerns about care) Provide technical assistance to staff • Identify deficiencies related to the facility closure and resident relocations. Advocateforchanges in public policy. Advise the State Ombudsman and Board

10. WORKING with OTHER OMBUDSMEN Relocation Specialist -Sits on Relocation Team -Refers to Regional Ombudsman -Monitors conditions -Advises staff -Reports on processes Regional Ombudsman -Does Case work -Takes Complaint referrals -Assists with appeals -Monitors conditions

11. Volunteer at the Closing Facility to Monitor general conditions Report concerns for conditions Introduce program and offer services Communicate developments to residents and families Take referrals for questions/complaints Volunteers at the Receiving Facility to Follow up on residents that relocate from a closing facility Introduce program and offer services Report on adjustment to new facility Take referrals for questions/complaints Work with Volunteers

12. INFORMATION and ASSISTANCE to RESIDENTS and their FAMILIES • Touring and introducing the Ombudsman Program to Residents • Participating at Resident and Family Informational Sessions • Setting up and maintaining a Resource Room. • Providing written information on residential options and services, funding, directories of nearby facilities and contact lists for agencies and programs. Brochures on the Ombudsman program, resident rights and recommendations for discharge planning • Presenting to the Resident and Family Councils • More Touring and meeting to maintain contact with residents

13. EDUCATION to FACILITIES • Reviewing elements of their Relocation Plan • Reviewing a Roster of Residents to identify potential obstacles for relocation (clarifying legal status, diagnoses, special needs.) • Recognizing and addressing Transfer Trauma • Providing Discharge Planning and Orientation • Working with the Relocation Team and understanding Processes (screening for funding, etc.) • Understanding Ombudsmen’s and other agencies’ roles

14. RELOCATION TEAM Wisconsin Statutes assign responsibility the state DHFS • Offer relocation assistance to the resident • Prepare removal plans and transfer trauma mitigation care plans • Assure safe and orderly removal from the facility • Protect the resident’s health, safety, welfare and rights Wisconsin Statutes authorize the state DHFS to • Place relocation teams in any facility for any reason for the purpose of implementing removal plans and training staff of transferring and receiving facilities in transfer trauma mitigation.

15. RELOCATION TEAM The DHFS Coordinator directs the activities of a “relocation team” that’s made up of representatives from the • Facility (Social Worker, Director of Nursing, Nursing Home Administrator) • County (Resource Centers and Care- Management Organizations) • State (Relocation Coordinator) • Advocacy (Ombudsmen and the Protection and Advocacy Organization

16. TRANSFER TRAUMA • Relocation Stress Syndrome, also called Transfer Trauma, is a formal nursing diagnosis and defined as “physiologic and/or psychosocial disturbances as a result of transfer from one environment to another.” It is otherwise defined as “the combination of medical and psychological reactions to abrupt physical transfer that may increase the risk of grave illness or death.”

17. REDUCING TRANSFER TRAUMA • The involvement of familiar people, the maintaining of consistent daily patterns and routines, and assisting the resident in becoming acquainted with new surroundings can help minimize stress associated with relocation. • Slow and thorough discharge planning that provides the resident with an opportunity to tour alternate living arrangements and, most importantly, that asks the residents what it is that they want can help ease the adjustment of needing to move.

18. DISCHARGE PLANNING • F204 Orientation for transfer or discharge A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.

19. Wisconsin’s Transfer and Discharge Activities HFS 132.53(3)(b)3. Transfer and discharge activities shall include: • Counseling • Opportunity to visit potential alternate placement • Assistance with moving • Provisions for medications and treatments

20. Wisconsin Requirements for Discharge Planning Conferences HFS 132.53(3)(b). Prior to any involuntary discharge, a planning conference shall be held at least 14 days before discharge to • Review the need for relocation • Assess the effect of relocation on the resident • Discuss alternatives placements • Develop a relocation plan

21. Post Discharge Plan of Care • F284 When a facility anticipates discharge a resident must have a discharge summary that includes : a post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment • HFS 132.45(5) Documents, prepared upon a resident’s discharge, summarizing needed continued care and instructions

22. Notice and Appeal Rights • F203 Notice before transfer Before the facility transfers or discharges a resident, the facility must notify the resident…of the transfer or discharge…in writing and in a language and manner they understand

23. Notice Timing and Contents • F 203 The notice must (usually) be made…at least 30 days before the resident is transferred or discharged and must include: • The reason for the transfer or discharge • The effective date of the transfer or discharge • The location to which the resident is transferred or discharged • A statement of the right to appeal the action • The name, address and telephone number of the State long term care ombudsman (or the protection and advocacy agency)

24. MONITORING CARE and TREATMENT • Staffing levels and Unmet Needs • Food and Menus • Activities • Certain Regulatory Standards of Care (for choice, notice, dignity, restraints and abuse.)

25. REPORTING CONDITIONS • To the facility • To the Department of Health and Family Services Relocation Coordinator • To the State Regulatory Agency

26. Other Duties as Assigned • Identify and report deficiencies in processes • Make recommendations to the department and the Board on Aging and Long Term Care • Assist in rewriting the State’s Relocation manual

27. Follow Up Activities • By the Facility • By the County • By the State • By the Ombudsmen • By the Volunteers • By the Regional Ombudsman • By the Relocation Specialist

28. Different Problems for Different Kinds of Relocation Activities • CLOSURES • DOWN-SIZING • REPLACEMENTS • Any/All of the ABOVE

29. PROBLEMS in CLOSURES • Stress of having to move (involuntarily.) • Not having options or knowing they exist. • Not being kept apprised of developments • Moving before being ready • Inadequate discharge orientation and planning • Being Unaware of Notices and appeal rights • Experiencing Subsequent relocations from closing facilities

30. Recommendations in Closures • Keeping residents and families informed and up to date • Explaining options and facilitating discovery • Repeated “mini” discharge planning sessions • Develop adequate discharge materials (summaries, post discharge plans.) • Demand some kind of notice • Follow up contacts and visits

31. Problems is Down-Sizing Facilities • Stress of possibly having to move (involuntarily) or to lose contact with other residents (survivors remorse) • Anger and resentment related to arbitrary decisions being made (unfair selection for being discharged.) • Loss of faith after being confronted with having to go through appeal process.

32. Recommendations in Down-sizings • Encourage facilities to plan ahead and to decrease census through attrition (to avoid involuntary discharges.) • Educate residents and families (and facilities) about the rights to notice and appeal • Monitor for violations of those rights and be prepared to assist in appealing a discharge decision.

33. Problems in Replacement Relocations • New buildings aren’t fully ready for occupancy (beds unavailable, call lights/electronic systems not operational.) • Residents/families unsure of details for the move • Residents’/families’ preferences aren’t accommodated (for room/roommate choice) • Residents aren’t fully prepared (belongings not packed or left behind.) • Staff aren’t oriented to the new building (can’t find equipment and supplies)

34. Recommendations in Replacements • Facilities should plan well in advance and expect the contractor’s dates to be off. • The regulatory agency should ensure the building is completely ready for occupancy well in advance of anticipated move date (and should require beds be made immediately available upon the residents’ arrival.) Plans should be required and monitored for implementation • Residents and families should be included in the planning and their preferences accommodated. • They should be offered tours and periodic updates on how the project is proceeding. • Belongings should be sent simultaneously and promptly unpacked • Staff should be oriented to the building and have access to all needed equipment and supplies. • Extra staff and volunteers should be on hand before, during and after the move.

35. Educational Materials Other materials include lists of area nursing homes, residential types, etc.

36. QUESTIONS ???

37. For more information, please call or write Tom La Duke; Relocation Ombudsman Specialist State of Wisconsin-Board on Aging and Long Term Care P.O. Box 180, Kenosha, WI 53141 (262) 654-4952 (800) 815-0015 Thomas.Laduke@wisconsin.gov