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Who is looking after residents in long-term care?

by Carol Bradley Bursack, Editor-in-Chief

Carol Bradley Bursack talks with Becky Kurtz, Director of Long Term Care Ombudsman Programs about how her office assists families caring for loved ones.

It is safe to say Becky Kurtz has a strong passion for helping residents in long term care. From serving as an ombudsman for the state of Georgia to her current role as director of ombudsman programs nationwide, she strives to improve the quality of Americans' care by advocating for residents' needs and interests. In an exclusive interview with ElderCarelink.com's Carol Bradley Bursack, Kurtz shares her insights, from the advice she gives families on choosing a care facility, to her confidence in the future of the aging boomer generation.

Carol Bradley Bursack: This is Carol Bradley Bursack, Editor-in-Chief of ElderCarelink.com here with Becky Kurtz, Director of the Office of the Long-Term Care Ombudsman Programs within the Administration of Aging (AoA). In her capacity as director, Becky spearheads ombudsman services for our nation's long term care facility residents and advocates for resident interests at the national level. Prior to working for the AoA, Kurtz served for 16 years as the State Ombudsman for the State of Georgia. She also has served as an attorney representing low income seniors with the Atlanta Legal Aid Society. How are you doing Becky?                              

Becky Kurtz: Fine, thanks. I appreciate the opportunity to talk with you, Carol.

Bursack: Thanks. It's just great to talk with you. I've been such an advocate of your program and written about it a great deal, so this is an enormous pleasure for me. You have a huge responsibility and serve as an important link in the elder care system. How do you feel about accepting this challenge?

Kurtz: It is an exciting opportunity. There's plenty of work to keep us very busy with new and interesting things to work on. One of the wonderful things about the long term care ombudsman program--and my 16 years working in the program in Georgia--is the program is a rare opportunity to combine helping real people solve their individual problems while looking at the big picture. How can ombudsmen improve care for the whole state, or the whole nation? Getting a chance to pull both of those together -- for individual problems to inform our greater policy on long term care -- is very rare and very exciting. I think the ombudsman program is a rare example of bringing those together.

Bursack: That's wonderful. I was just doing some research on your background and realize that you are the first one to hold this position.

Kurtz:  You're correct. I am the first one to hold this as a full-time position. Some of the duties were covered by other individuals, but this position was written into the Older Americans Act in 1992 and I'm the first person to hold it as a full-time position.

Bursack: Well, congratulations on that.

Kurtz: Thank you.

Bursack: According to the information you sent me, each state has a long term care ombudsman program, which works to resolve problems of individual long term care residents. In other words, it works for people who live in nursing homes which include things like rehabilitation units and assisted living. I have to say I wasn't aware that it [the ombudsman program] worked for assisted living, other board and care, and similar adult care facilities. Could you tell me how the program is staffed? Volunteers or paid staff?

Kurtz: Absolutely. First, let me say the program also includes some U.S. territories. We have an ombudsman program in Washington D.C., Puerto Rico, and in Guam. Those states or territories decide how they want to structure the program, within the guidance of the Older Americans Act, of course. But, some states house the program in state government, some house it in nonprofits and some do a combination. While some states use staff primarily, some use volunteers primarily, so each state is designed a little bit differently. The most common model is to have the state ombudsman and their state-level staff be state employees. For local one-on-one services with residents, it is common to use area agencies on aging or nonprofit agencies on a contract basis.

Those local or (sometimes called) regional programs tend to serve their communities either through volunteers or staff. It just depends on how the state has structured it. But in general, if you look nationwide, about 1,300 people work as staff members in these programs. Not all are full-time staff members; sometimes they wear different hats. And, about 10,000 across the country are volunteers working in the program.

Bursack: Wow.

Kurtz: Now the majority of those receive training and certification so they are qualified to investigate and resolve complaints for the residents.

Bursack: That's great. I remember meeting a gentleman who used to visit with all the elders at a local nursing home.  I was there almost every day through my two decades of elder care. And the guy was just great. I assumed he was a volunteer in my state, so this is really interesting to me about how you staff.

Kurtz: It is very state-focused so anyone interested in learning about their program should learn about how it is structured in their state, because some states rely very heavily on volunteers. But it does vary from state to state.

Bursack: That is great information.  I do direct interested individuals to their state website often because every state is a little different even when it comes to Medicaid, so we just need to have them find out their state rules. Given this information, I do have a question. I'm asked often by passionate family care members -- and I know where that passion comes from because I've been there -- about resolving issues. Sometimes they have unrealistic expectations, sometimes they're just cranky, and sometimes they have real complaints. What I generally tell people -- barring abuse of or something very serious -- is to try and resolve the issue with the hands-on caregiver [the certified nursing assistant or somebody] because often it's just a misunderstanding. If that doesn't work then perhaps talk to the floor nurse and go up the chain of the administration of the nursing home or facility. Then, if nothing works, you've got a real issue. If it reaches that point, they should contact their state ombudsman. Am I correct here or should I be changing my approach? What do you think?

Kurtz: No, that's exactly the advice ombudsmen would give families. Ombudsmen would start off by saying, “See if you could solve it yourself within the facility. Start where the problem happens and move up the chain of command depending on what the issue is.” For example, if the issue is dietary, you would speak with the dietary staff, not the nursing staff.  But wherever the issue is, you deal with it as directly as you can first and move your way up through the hierarchy of that facility. If you can't resolve it, ombudsmen are always happy to help -- that's what we do. We investigate and resolve problems for residents and their representatives. The other piece of this, of course, is ombudsmen are not regulators. Ombudsmen can't force the facility to do anything. Ombudsmen do not have any regulatory authority. They are informal dispute resolvers. If you want an advocate; if you want an individual who can get in there and really try to negotiate a solution, that's an ombudsman. If you want an entity that licenses the facilities to do a formal investigation and look at it from a regulatory point of view, that's not the ombudsman. It's important to know what the resident's goals are and what the kind of problem is to know whether it's most important to contact ombudsmen or the state licensing and regulatory agency. If you contact the ombudsmen, they usually help you think though that.

Bursack:  That's good. They would talk with people then and say, you know, let me give you some information here and you can take it further if need be?

Kurtz: Right. Often, ombudsmen are going to help a family or the resident, whoever is giving the call, by helping them think through their options. “Here's what I can do as an ombudsman. Here's what a regulatory agency could do.” You might want to file a complaint with both, or one, or the other, depending on what kind of issue it is and what kind of outcome you're looking for.  Now ombudsmen are able to resolve over 75% of the complaints that they receive, and the greatest majority of those never have to go to a regulatory agency. A lot of times it is good to start with the ombudsman because they might be able to resolve it without having to go through that more formal system. For example: a roommate dispute. Two residents have a concern they can't seem to resolve. Ombudsmen might get involved in this issue, but it may have nothing to do whether the facility is actually doing something wrong. Another example would be a resident who is trying to get a Medicare benefit or some other public benefit resolved. While the facility has some role in assisting, it's really an issue between the resident and that public agency. It's not that the facility is doing something inappropriate.  Regulators won't necessarily get involved in those cases.

Bursack: That's interesting because it's good to know the difference between the two. There again it's almost part of a chain of command, but also the fact is your office is more of a mediator. Is mediation a good term to use at all when it comes to your office? Is mediating helping people smooth over rough edges, so that they don't take a further step they don't really need to take?

Kurtz: Your definition is a good one. I usually steer away from the term “mediate” and use “negotiate” only because a mediator by formal definition is a neutral party. But in the ombudsman program for long term care -- this is not true for every ombudsman program in the world -- but the long term care ombudsman program focuses on resident interests. There is a bias in that the ombudsman is there for the resident, as opposed to the facility or the public agency or even the family if there is a dispute between the family and the resident. The resident's concern is, by law, the ombudsman's primary interest so that's not a mediator in the sense of a neutral party that would see all parties involved in the dispute equally. The ombudsman is there as an advocate for the residents' interests.

Bursack: That's a very, very good distinction. I'm glad you explained because it will definitely help people know and understand your role better. I have another question: the website I generally give people when they want to locate their own ombudsman other than going through their own state. It is www.ltcombudsman.org and when I bring that up it brings me to the national long term care ombudsman center -- is that your official website you would give? Is that part of the AoA or should they be going to a different site?

Kurtz: That is the best site to give. It has on that first page, a map of the U.S., and you can just click on your state. It takes you directly to, not only the ombudsman, but the other key players in long term care in your state.

Bursack: That's why I love the site.

Kurtz:  I'm glad. The National Ombudsman Resource Center is actually funded by the Administration on Aging. The AoA funds the Resource Center for exactly that purpose, to give information to the public about the ombudsman program and to support long term care ombudsmen across the country through training and technical assistance.  

Bursack: That's great. I just like to know if there's another angle I should be looking at that I know about, and so far …

Kurtz: No, you hit the best one (laughs).

Bursack: That's great. I'm wondering what are some of the most common problems and issues you deal with? Can you give us some examples? Or say one of your volunteers or staff?

Kurtz: Sure. Why don't I just tell you what the most common complaints are that ombudsmen receive?

Bursack: Great.

Kurtz: For nursing facilities, the top five complaints received last year were in the following categories. The first one is unanswered requests for assistance. Usually that's call bells that aren't getting a timely response from staff. For example, a resident needs assistance with toileting or their food is delivered in their room and they aren't satisfied with it, or they've fallen and are trying to get assistance. Whatever the issue, they are trying to get assistance and it's not timely. That's the very most frequent one ombudsmen get nationwide.

The second one deals with issues around the discharge of the individual or the eviction of the individual from the facility. For example, the individual is supposed to get a 30-day notice in writing before they are discharged from a facility against their will. That doesn't always happen or the notice is not provided appropriately to the resident and the representative. Or, the reason for the discharge is inappropriate. Ombudsmen also have issues where residents are sent to a hospital and then they are told by the nursing home, “Oh, we're not going to take them back.” That's not appropriate. Those types of issues are very appropriate for ombudsmen to get involved in and to help residents and their families know what options the residents have. They do have a right to an appeal process and educating residents about those options is a very important ombudsman function.

The third one is about lack of respect for residents by staff. Poor staff attitudes. Now sometimes this is because there's a staff person who isn't doing their job very well. Sometimes it's also because staff members are completely overwhelmed and overworked. From the resident's perspective, “this person is not being friendly to me.” There could be several reasons for this, but that is another very frequent issue. The other kinds of issues ombudsmen get very frequently in the top 5 of nursing home complaints relate to food-related issues and medication-related issues.

Bursack: I get emails everyday and answer questions from people on all those issues. And some of them I would think, this is where I tell people that perhaps if they discussed it starting with, say a floor nurse or something of that nature, would be a good idea. But, assuming they have done that then they can get help from someone in your office. What would you say to someone who didn't even really make much effort to talk to someone in their nursing home to, and they're just saying, “My mom's bell is never getting answered." Then they call your office. What would be your response or what would be you or your volunteer's response to that?

Kurtz: Well, it's interesting because typically what ombudsmen are going to do whenever they get a complaint is to find out if it is a problem for the resident. Sometimes the resident's goals are not the same as whoever is bringing the issue to the ombudsman's attention, whether it is a family member or a staff member. Typically, the way it works is the ombudsman will check with the resident. And if the resident can tell them they have a concern, they'll work on that concern. Sometimes the resident will tell the ombudsman they don't have a problem, or that they have a different issue that is more important to them, or they frame it differently. Sometimes residents can't tell the ombudsman, because of their disability or cognitive impairment or confusion.  If a resident can't tell the ombudsman, then the ombudsman is typically going to go with the representative or the complainant and work on the issue they're seeing.

The first thing ombudsmen do is check whether they can advise either the resident or the representative of what solutions or what strategies might be available to them. Ombudsmen help residents and their representatives learn how to advocate for themselves and their loved ones. But, if they can't get it resolved that way or they feel like they've done everything they can, then what are their options? How can ombudsmen help? For example, if an individual's dietary needs are not being met and the family's bringing that to the ombudsman, then the ombudsman might say to the family: “Here is how you can do it. If you want us to do it, then here's what we might be able to do in terms of going directly to the dietary folks and seeing if we can come up with the resolution.” Or, one of the really frequently used advocacy tools is to ask, “Have you talked about it in the resident's care plan?”

Bursack: Right.

Kurtz: There's a care plan meeting in nursing homes. I'm only talking about nursing homes right now. There's a care plan meeting in nursing homes that happens at least once a quarter.  It is an opportunity for the resident and their representative to talk about the goals of the resident's care and what kinds of things should the facility be doing to meet those goals.  It's sort of a road map. It helps families and residents know what is appropriate to expect. This facility said it was going to do this and it's not doing it, or this facility said they're going to do this and that's exactly what they're doing.

Bursack: That's right. Expectations, I think, are huge. Expectations of family members -- especially -- because they love their care receiver. They want the best for them, but sometimes they can be unrealistic. So these care planning meetings are very important.

Kurtz: They're important not only because they help the resident and family members with expectations (which is very important) but is also the thing that regulators looks at. So if the facility said that they're going to do this strategy to help mom not fall, or they're going to do this strategy to help mom get her nutrition and they're not following their plan of care, that is something that regulators will examine. It gives the family a good clear sense of what the facility should be doing, as well as, if they're not following it it's a very clear road map for regulators to hold the facility accountable. Care plans are important documents that people don't use nearly enough.

Bursack: That is very interesting information and I'm tucking that one away for sure. I've got another question for you, about the boomers, which I assume you expected because that's all we hear about. But as the boomer generation enters our senior years, the growing need for caregiving is at the top of mind with a lot of families. What is your office looking at to meet this growing need? What are your thoughts about this? Does it sound as dire as some of the predictions that we see?

Kurtz: Well there are a couple of things. One: it is the boomers who are the family members that are calling ombudsmen frequently these days.

Bursack: Right now?

Kurtz: Right. And one of the great things about the boomers, generally speaking is that they have high expectations and they're savvy. They know how to do research on the web or how to call and make demands on what they need and expect. I actually think that is the most hopeful thing for long term care in the country. We have consumers who are smart, that are doing their research doing their homework and are not putting up with less than quality care. I think that that's fabulous.  I love that they're calling the ombudsman program or calling the regulators or talking to the facility and saying here's what we need; let's work on it.

Bursack: That's part of the culture change that we're working toward. I write about that a great deal because this is what's needed -- a change in attitude and culture -- and I think boomers are pushing that.

Kurtz: I do too.

Bursack:  Knowing that they are going through your office is great and this leads to my next question. How is your office involvement changing as the need for caregiving increases? I think you have kind of answered that in that you really want the involvement of the advocates for the elders and the seniors and then the boomers that will become the seniors. Is there anything that you'd like to add to that before we move on?

Kurtz:  Well, I want to say a couple things about ways ombudsmen help those family caregivers right now and then where that might go the future. In addition to the complaint resolution we've already talked about, supporting families in terms of getting good care, and advocating for those residents, ombudsmen also provide a lot of individual advice to folks who are calling. “How do I select a facility? What is my family member's right? What is appropriate for me to expect as a family member? How can I as a family member be involved as a caregiver even if I'm not doing the care directly in my home?” Family members need to think of themselves as caregivers even when the individual is in a facility.

Bursack: I write about that issue all the time.

Kurtz:  They're so important to the well being of that family member. They need to stay involved and be very active caregivers.  One of the things ombudsmen do is provide individual advice and consultation to families. Last year, ombudsmen did that over 300,000 times. Ombudsmen give families a lot of information. The other thing ombudsmen do is support family councils. They don't exist in every facility. And where they don't exist sometimes ombudsmen can be very helpful in their development. But last year, ombudsmen attended over 4,000 family council meetings. Ombudsmen help family councils think through strategically, “How we can improve care in this facility?”, or whatever the issues are that the family council wants to bring as a focus. The other thing, I think, is thinking strategically, “How do we help families become savvy consumers? How do we help them get those tools?” To me, that's the future of this program. In terms of help families, giving them the tools they need is vital because sometimes families with the right information and right tools can resolve a lot of problems themselves.

Bursack:  That is terrific, and it's going to be needed. Many more people need help but also the education. I write about education a great deal because I think educated patients and educated caregivers are very helpful. I always talk with people about saying you're still a part of the care team and tell them to approach the facility people in a friendly manner, and to want to be a part of it. Some people have almost an adversarial approach and all that does  -- in my view -- is start people off in a negative way with the facility.  I did see some news about expanding your program to serve the transitioning from one type of care to another and, of course, we have a great deal of that people going from assisted living to a nursing home, that kind of thing. How has this changed from what you've done in the past? Or has it not?

Kurtz: Beyond the ombudsman program, there's a new initiative that started in October. I'm going to give some jargon here. It's called the MDS 3.0. MDS is the minimum data set and 3.0 is the new version. That is the tool that all nursing homes across the country use if they receive Medicare, Medicaid or both, which the vast majority of nursing homes do. That tool is required to be used for every resident when they are first accessed when they come into the facility to determine their needs. Every quarter or upon a change in condition, there's this assessment of the resident by the nursing home. Is the nursing home meeting those needs? One of the big changes that started last October, is this new tool asks a new question, and that question is asking the resident, “Do you want to talk with someone about the possibility of returning to the community?” That question has pretty significant implications.

Bursack:  Oh very, very significant.

Kurtz:  Residents are going to be routinely asked about their interest in getting information, so the nursing home staff is the one that asks that question.

Bursack:  And that is new.

Kurtz:  Yes, that is new for sure. And like I said, it started in October across the country.  The issue is if the resident says “yes” -- and our expectation is that many, many residents will -- then the nursing home has a duty to contact what's called a Local Contact Agency. This is somebody outside the home who has expertise in knowing about what services and support are in the community, whether that be in the person's own home, or with their family, or maybe even a different kind of facility that's less institutional than nursing homes, such as an assisted living option. One of the things the ombudsman program is very involved in is helping to successfully implement that question. If the resident answers “yes”, then ombudsmen help the resident make sure they got asked the information, make sure the resident got the question as they were supposed to, and make sure that if they get information, ombudsmen can help support them through their decision making process. Ombudsmen are not the ones who set up the new placements for them, that's not an ombudsmen's job, but if there are problems through this process, if they got wrong information, or didn't get the information they needed or someone didn't ever respond to their needs, ombudsmen are the ones who try to resolve the problem to make the system work for the resident.

Bursack:  That is really wonderful. It's a huge step forward because the cost of nursing home care is huge and I know that many states are looking at ways to help people stay in other types of care with assistance before moving them to nursing homes.

Kurtz:  Yes, I think it is a very exciting opportunity. I also think it's very important for residents and families -- which gets back to the point you brought up earlier -- to have reasonable expectations. Helping residents and their families think though what really are the services available? Are they appropriate for this individual? What are the wishes of this individual and how can ombudsmen help the individual resident meet his or her own goals? Sometimes that might be “Hey I want to go back home." One of the things that the ombudsman program constantly tries to do is to remind everyone that it's about the individual; it's not a cookie cutter approach. Not everybody is cut out for the same kind of support and services so ombudsmen try to make sure that the individual doesn't get lost in that process.

Bursack:  That is wonderful. It is part of this new person-centered care, which I'm pleased to see develop more and more across the country. It's a new piece of the puzzle and it's wonderful. The next question kind of works into that too. Somebody calls your office and they want to know what they should look for when searching for a caregiving facility or for services. You would help them then in the same manner I assume? Help them sort though some of the options?

Kurtz:  Yes, let me say three things about that topic. When people call an ombudsman and ask for help, there are three things they ought to be doing. One is information gathering. Second is, if you need a facility, what type of facility do you need? And third is comparing those facilities. The first step, information gathering starts by asking "what does your loved one need?" Sometimes, the only option that people hear about, are nursing facilities. That's especially true if they're in a hospital, and they are given a list of options of next steps. Sometimes they don't know that if they would talk to their area agency of aging or their Aging and Disability Resource Center, they might learn about an array of options that might be appropriate.  From the beginning, getting some information about the array of possibilities, where those services can be provided, and what's appropriate given the need of this individual. That's where you start. The second part is, if you need a facility, if you need that round the clock care in a residential setting, then knowing the difference between a nursing home, an assisted living, and a board and care facility. This is not as easy as you would think because there's a lot of confusion out there. Just today, I read a newspaper article with the headline “Nursing facility closed due to abuse” and when I read through the article, it wasn't a nursing facility.

Bursack:  [Laughing]

Kurtz:  It's very, very common that people use the term nursing facility or nursing home about everything that is elder care that is residential. And that's not true.

Bursack:  I've heard the same thing.

Kurtz:   It's confusing, so the first thing to do if you're looking for a facility, ask the facility, “How are you licensed?” They'll use different terms. I had a conversation with a family last week where the family member said, “My father's not in a nursing home. He's in a rehabilitation facility.” And I said “But I'm just going to look up on the Internet to see how this is licensed.” And I did, I went to medicare.gov and sure enough it was licensed as a nursing home facility, but the family, which is a very highly educated family, thought he wasn't. They used different language. “Rehabilitation facility” and “sub-acute care” are different types of terms that are used, but the facility might still be a nursing home so you have got to know what you're actually dealing with so you can compare facilities.

Bursack:  Oh, definitely.

Kurtz:  "Assisted living" and "board and care." Those are two terms that are different in every state, including how they're licensed, what they're called, and what kinds of services you can get there. Can a nurse provide services or not? It all depends on where you live. There are no national standards. And that makes a big difference in terms of when you're looking for care. If mom needs some nursing supervision, can I get it here? And what level of that nursing care can I get here? So knowing what's available in your state for those kinds of facilities is absolutely critical.

Bursack:  It is. This is what I find too. People actually get angry with me kind of just because they're so exhausted when I tell them they have to go through the state. But you know that is just how it is.

Kurtz:  You have to. It's just how it is. It's not the same across the country. They might be called “adult foster care,”“personal care homes,” “assisted living” or “adult residential care.” There are a variety of terms that states use, so it is very important to get the right term and then find out what your state allows in those types of facilities. Once you figure out what you need, start comparing your facilities. If you're looking at nursing facilities, it's a little easier. It's not easy but at least there are some national tools that are available for every nursing home, at medicare.gov. There is lots of information to compare nursing homes with each other, such as their inspection reports, quality measures and staffing.

Bursack:  I was just going to say one thing that I found by going to that particular tool, and it's a very valuable tool, however there again, the states work into it and I just by comparing what I knew about local facilities here, and talking with contacts around the country, it seems that a nursing home could get two stars in one state may get five stars in another…

Kurtz:  Because the surveyors are different.

Bursack:  Exactly. And state standards, say what they inspect are different and so what I do what I tend to tell people, is very valuable tool but don't use it as your only tool because it does once more depend on where the facility is located. Am I correct there?

Kurtz:  You are correct there. Although, let me say, that the surveys that are reported on this site are all done under federal regulation, so there are some commonalities among the surveys, but most of the time, families are looking in one geographic area. They're not, comparing Massachusetts to California so if you're looking up facilities in your state, chances are that you're comparing apples to apples. The other thing though is, that you're absolutely right, use that as one tool, not the only tool, because even more important than that information that you can get off of the web that compares facilities is visiting the facility and seeing it for yourself. Seeing how residents and staff interact. Are staff members respectful? Are there enough staff members? What does the place look like? What does the place smell like? What are the sounds you hear? Is this a comfortable place for where you would want to visit as well as for your loved one to live? And there are two things I always tell people to not pay attention to: fancy titles and pretty wallpaper.

Bursack:  Very good. [Laughing]

Kurtz:  Those don't tell you anything about care.

Bursack:  No they don't.

Kurtz:  You want a pleasant environment but they tell you nothing about care.

Bursack:  One thing I tell people is to see how the staff interacts, because it seems to be that when the staff interacts with each other well, you've got a happier staff. You've got more cooperation between the staff and that would translate to better care overall.

Kurtz:  I think that's very good advice.

Bursack:  Yeah, I've seen places where the CNAs are treated with great – and they should be – with great respect. They are the hands on people. They are the ones who are helping the elders so much and if they're happy with their job, your loved ones are going to get better care, than if they are feeling put down.

Kurtz:  That's very good advice.

Bursack:  Okay. Well you know that's good. I'd love to hear about what everyone else has to say but just from my personal experience that was important, so it's good to know that what I'm passing on is something that you would consider good too.

Kurtz:  The other thing to think about is where the facility is in light of where the resident will have visitors, so does family have easy access? Is this in the community where the resident has lived, so that their friends can easily come visit them? The quality of visitation at the facility can make a big difference in the quality of life for this individual and their ability to stay connected to their community.

Bursack:  Oh it's huge. In fact, I'm often asked, should we move mom to be closer to us? And then I post some of these same questions because it can get very sticky, sometimes family is in one part of the country and the parents are in another and sometimes there is no choice but also they have to take these things that you're talking about in consideration. Are you yanking them out of their historic place of living, where their friends are that kind of thing? So families have a lot of very important things to examine.

Kurtz:  Exactly.

Bursack:  Great points there.

Kurtz:  If families are trying to compare assisted living facilities or board and care or other kinds of facilities we talked about, like I said before, that's going to depend on your state. Many states, increasingly, are starting to provide comparison tools on their websites. You can also get inspection reports from your state. Those are public documents. If they're not posted on a website, you can call your state health department or licensing agency, and tell them you want to see the latest inspection reports. So you know what kind of problems there have been, if there have been problems.

Bursack:  Yes, that and check with the county. Depending on where people live, they need to find out where the licensing is and who does the inspection., I'm also a huge advocate of word of mouth because families, I mean, I don't believe that people should just ask only one family because some family members or their loved ones at a nursing home are never going to be satisfied, where another one will be satisfied with darn near anything so I think it's really nice to get several opinions. Word of mouth is one of those things that I've found very useful if you know the general area where you want the person to live.

Kurtz:  It's helpful to hear what other people's experiences have been. Sure.

Bursack:  Definitely helps and how they interact with staff. Well, I've got a couple more questions before we wrap up. I know we really kind of answered it, but I'd like you to answer it in your own words, is how can people contact their local ombudsman?

Kurtz:  ltcombudsman.org is a really handy place to go. For those individuals who don't have Internet access, they can also call the Eldercare Locator, that's 1-800-677-1116, and that number -- if they can say the zip code they're looking for, the state or community -- can link them into where their ombudsman is as well, so that's another option. I think the National Ombudsman Resource Center is the most convenient way to learn about how to contact the local ombudsman in your area. Also, in most states, there is a poster in the facility, so if someone has already got a loved one in the facility, then they should just look around in the facility. There's probably a poster up that says, “Here's how you reach your long term care ombudsman that serves the residents in this facility.”

Bursack:  I remember that, as a matter of fact, and that is very good advice because everything can seem so hurried when someone does go to a nursing home and then you don't always pick up on this as a family member whose maybe worried or something and then you see this information but that website, ltcombudsman.org is just excellent. It's just very well put together. It's intuitive. I don't think that people have to be a real web whiz to use it, so I think that works well for people. How can resource and community sites like ElderCarelink.com and others help, how can we help you get the message out? I have written about you a number of times. I'll continue to do that. Are there other things that we can do to help get the message out about all these wonderful services that you offer?

Kurtz: First of all, we appreciate what you already have put on your website. I did some looking around and have seen several places where ombudsman program information is available so we're very grateful for that. One of our biggest challenges is getting the word out about ombudsman services because a lot of times, people don't really need to know about the ombudsman program until they know someone in a long term care facility and then they have so much to learn it's overwhelming. And it doesn't help that ombudsmen have a title that's difficult to pronounce.

Bursack:  [Laughing]

Kurtz:  Well, ombudsman is a Swedish word, not originally an English word, so it takes time to know what an ombudsman is and does. So that takes some explaining, but certainly providing information on your website about the kinds of services ombudsmen provide helps us continue to get the word out. We appreciate you spreading the word about long term care ombudsman services. Ombudsmen have got plenty to do. On average, we have about 2,500 residents per staff ombudsman, so there are a lot of residents per person out there to keep ombudsmen busy. Sometimes we don't do a good job as we could of making sure everybody knows about ombudsmen services, and we really do want people to know that ombudsmen are available to help residents. You'll find that ombudsmen are very, very passionate about wanting to help residents resolve their problems.

Bursack:  I have seen that firsthand and been very impressed with just my limited encounters that these are people who the volunteers are the ones I've run into and you can tell that they are doing this because they have a passion and it is just wonderful to see. Is there anything else you want to add Becky before we wrap this up?

Kurtz:  I think maybe we have some issues that we can delve into further in the future. But I think this is a good overview of how people can use the ombudsmen program for their long term care needs and their questions and for advocacy for their loved ones, so I think that's good.

Bursack:  Well, I think it's great too. And I was going to ask you if we can certainly connect in the future. And I'm right and certain to tap you now that I know you're a wonderful resource.  Hopefully we can chat again.

Kurtz:  Thank you so much, Carol.

Bursack:  You just keep doing what you're doing.

Kurtz:  You too. Thanks so much.

Bursack:  Thanks again to you. We've been talking to Becky Kurtz, Director of the Office of the Long-Term Care Ombudsman Program.