This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

A Michigan family didn't approve of their grandmother having a boyfriend, so they activated a power of attorney she'd set up in case of incapacitation, moved her from a temporary rehab setting to a nursing home across the state, and took away her phone and laptop – all despite her having her full faculties. But with the help of the Michigan Long Term Care Ombudsman Program, the grandmother was able to revoke the power of attorney, move out of the nursing home, and go home to the last love of her life.

Michigan Ombudsman Sandra Reno shares this story, omitting the woman's name to protect her privacy. It's just one of many success stories for MLTCOP, which is housed within the Michigan Elder Justice Initiative (MEJI). As advocates for the rights of over 100,000 older adults and adults with disabilities in Michigan, MLTCOP ombudsmen improve quality of care and quality of life for people living in nursing homes, homes for the aged, and adult foster care homes. MLTCOP services are confidential and free of charge.

The program currently enlists 20 paid ombudsmen and 11 volunteer/student intern ombudsmen. According to MEJI Director and Managing Attorney Alison Hirschel, one of the program's most meaningful applications is helping nursing home residents stay in their facilities when they have behavioral challenges. Too often these residents are instead moved to psychiatric hospitals.
Alison Hirschel.
Ombudsmen investigate resident concerns regarding abuse, neglect, exploitation, eviction/discharge, hospital dumping, Medicaid eligibility, guardianship, and harm to residents. They respond to notices of involuntary discharge, attend resident care planning meetings, and conduct regular visits to licensed homes. They also provide information and assistance to residents, families, and staff, and provide training and information on long-term care topics.

Efforts are underway to increase funding for these crucial advocates. Hirschel shares that while Ohio, Pennsylvania, and Illinois annually spend millions to fund ombudsmen — $2.17 million, $4.3 million, and $6.78 million respectively — Michigan only spends $822,000 a year.

"There is a long-standing national recommendation that each ombudsman be responsible for no more than 2,000 licensed beds," Hirschel says. "In Michigan, more than half the local ombudsmen are responsible for more than double that number of beds, a quarter of the local ombudsmen are responsible for triple the number of recommended beds, and one ombudsman is responsible for almost 12,000 beds."

Enforcing rights, responsibilities, and quality of care

The most common complaints that ombudsmen hear include involuntary discharge; failure of nursing home staff to address requests for assistance; patient rights and preferences being disregarded; personal hygiene, medications, and personal property concerns; and the need for dignity, respect, and a less restrictive living environment.

"We are individuals who have been given access to long-term care settings and work to help resolve concerns that are brought by those residents or by other concerned individuals," says Salli Pung, state long term care ombudsman with MLTCOP. "When we do visits to the nursing homes, we advocate for individuals. Some of the ombudsmen in our program are social workers. Some simply have committed themselves to make a difference in people's lives."
Salli Pung.
Nursing home residents have legal rights, and nursing homes receiving Medicare or Medicaid dollars are required to display a poster outlining those rights. Nursing homes are also required to notify the ombudsman program when they seek involuntary discharge of a patient, for example, when behavioral health issues become evident.

"A person has the right to remain in a nursing home and they can only be involuntarily discharged in certain circumstances. Those are spelled out in the regulations," Pung says. "One of the first things that we do [is] try to gather more information on the residents. We will talk about what other interventions have been tried and what's changed recently that might have impacted their behavioral health. Moving them to another setting is not always the answer."

In addition to helping individual nursing home residents, MLTCOP advocates for policies, procedures, and legislation that better serve all Michiganders who may find themselves requiring long-term residential care — a number that will only increase with the state’s growing population of older adults.

"We oftentimes will testify on legislation. We speak on behalf of residents and try to improve the system," Pung says. "We also have opportunities to meet with individuals at the Michigan Department of Health and Human Services and Michigan’s Licensing and Regulatory Affairs agency and primary payer sources for Medicaid services. We talk with them about policies or procedures where change is needed, or new policies or procedures [are needed], to help support residents."

Pung and her colleagues at MLTCOP are also actively involved in the Michigan Attorney General's Elder Abuse Task Force. Past accomplishments include continuing medical coverage for survivors of automobile accidents with traumatic injuries prior to the state’s auto insurance law changes. MLTCOP also weighed in on minimum staffing requirements for nursing homes receiving Medicare and Medicaid funds. Current initiatives include improving Michigan’s guardianship requirements.

"When I can get up every morning and know that I'm probably going to make an impact on people’s lives, that’s a fantastic thing," Pung says. "But that only happens because I have this fantastic group of 20 people across the state who provide those services at a local level. It’s an honor leading this program and making a difference for people."

A listening ear and confidential legal advocate

Reno is one of those 20 paid ombudsmen. Under the auspices of the Area Agency on Aging of West Michigan (AAAWM), Reno works with nursing home residents in Allegan and Kent counties.
Sandra Reno.
"We can go into any home for the aged, adult foster care home, or nursing home that is licensed," she says. "We provide anything from information to assistance, which is maybe by telephone or during a routine visit. If they have questions and want some information about resources, we can provide that. We can also open up the gate for somebody if they request assistance. Everything that we do is resident-driven."

Before becoming an ombudsman, Reno was a social worker in nursing homes for 30 years.

"I’m so very happy to be on this side," she says. "It’s the perspective that I always should have had. But unfortunately, when you work in the industry and you work for that company, ultimately it makes it a little difficult."

Reno has helped many nursing home residents escape guardianships that ill served them. Under current state law, a person in medical crisis without an advanced directive can be court-appointed an emergency guardian to make medical decisions for them. The guardians can take total control of the person’s medical decisions, finances, social connections, and property — selling off homes, throwing away possessions, and moving their wards into nursing homes even when they are able to live independently.

"A number of people that get guardians when they're in the hospital or medical crisis don't ever get rid of them," Reno says. "So, they have somebody that's appointed over them, making decisions for them, unnecessarily working with them. A lot of them can get terminated if they are not needed anymore. But they end up going on for a long time because nobody questions that or has told them you can try to terminate it."

Reno's first success story involved a woman who asked for help because her professional guardian had taken away her prescription for a medication that helped her go to the bathroom.

"We got it back for her," Reno says. "It was a different kind of victory. But it's an example of the control that [guardians] sometimes exercise that they shouldn't be without communicating with the resident."

Reno believes that the ombudsman program is important for Michigan’s adults and adults with disabilities — but worries that a lot of people aren't even aware of it.

"People are in these settings and don't even know what their rights are. The nursing home owners aren’t giving them that information. They're just unknowingly housing people instead of letting them live," Reno says. "Having somebody who doesn't work in that setting where they live, that's an outsider but on their side, that gives them a lot of comfort, even if it’s just giving them information. And we just don't listen to the residents. They’re being heard."

You can reach a local ombudsman at (866) 485-9393 or www.MLTCOP.org. The website also provides free fact sheets in Arabic, Chinese, English, and Spanish and a booklet on advance directives.

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Salli Pung photos by Doug Coombe. Alison Hirschel photo by Roxanne Frith. Sandra Reno photo courtesy of Sandra Reno.