As New Jersey's Ombudsman for the Institutionalized Elderly, James McCracken has what some might define as an impossible job: protecting the more than 30,000 nursing home and assisted-living residents in the state from abuse, neglect, and exploitation.
Clearly, it's not a job he can do alone. That helps explain why McCracken is hoping to double the number of volunteer advocates he works with. His office also has an 11-member investigative team comprising former state troopers and nurses who are dispatched to a facility to gather information and intervene if they find something wrong. (Last year there were 2,648 verified complaints, about the same number as the year before.)
But McCracken's investigative team typically tracks down tips and reports of suspected abuse. His volunteer advocates help him learn more about conditions at long-term care facilities. Right now, the program includes about 180 volunteers, up from some 145 when he came onboard. His goal is to reach 300 over the next two years, covering at least 80 percent of New Jersey's 369 nursing homes and 214 assisted-living facilities.
Volunteer advocates receive 32 hours of training and are assigned to a facility, which they visit for four hours a week. They get to know the staff and the residents, and become the eyes and ears of the ombudsman, advocating on behalf of the elderly residents.
Yes, they follow up reports about abuse and fraud. But they are also there to assist in a myriad of ways, helping one resident file her taxes, finding a baseball fan to share the room of another, and simply talking about opera once a week to a lonely senior.
The volunteer advocates, "work hard in the facilities to resolve complaints before anything ever happens. Frankly, that is why they are so important," McCracken said. "The volunteer will get a complaint from a resident or a staff member, and they will look into it and get it resolved before it escalates."
Perhaps a resident is unable to sleep with a noisy roommate; the volunteer will "talk to the social worker and facilitate a room change," McCracken said. Residents confide to volunteers about issues they hesitate to rise with the staff -- since it may be an attitude or behavior of a staff member that they're unhappy with.
McCracken's investigative team tends to deal with grittier problems. Cases might include a resident who has been hit by a staffer or fellow resident, verbal abuse or bedsores that indicate substandard care. Financial exploitation of the elderly is a growing issue.
The summary of an actual intervention can help put in perspective some of what the investigators deal with: "Received a call from the daughter of a resident. The daughter overhead an aide yelling at the resident in the next room to 'shut up . . . and eat your dinner.' The aide's comments were laced with profanities." That complaint resulted in the aide being fired and reported to the state board that certifies nurse's aides.
Once the complaint has been confirmed, the investigator "makes sure the issue has been resolved properly, and that there are procedures put in place to make sure the resident is free in the future from being subject to having this type of thing happening again," McCracken said. "We talk to the resident and make sure they are satisfied that the facility took the issue very seriously and appropriate action has been taken so they are not living in fear anymore."
Many cases are reported to the ombudsman by the facility itself: under New Jersey law, long-term care facilities are required to report any suspected cases of abuse to the state. Others are called in on the office's toll-free number -- 877-582-6995 -- from staff and former staff, relatives, friends, and the residents themselves.
McCracken said "Anybody can call our office -- the residents, the family, direct-care givers -- anyone concerned that something is happening can call our office, and they do. But it is important to note -- I constantly have to tell people this—that we are not emergency responders. If there is a crime being committed people need to call law enforcement."
The ombudsman is not an enforcement agency; once a complaint has been verified by an investigator, McCracken's office will refer the case to the appropriate agency, which may be the state Department of Health, which licenses the facility, or the professional boards that licenses aides and nurses, or the attorney general's office or the FBI if the matter involves theft of the resident's money.
The financial exploitation of the elderly is a growing problem, McCracken said, accounting for 16 percent of complaints in fiscal 2010, up from 10 percent in 2006. A friend or relative who has power of attorney for the resident may start taking the money "to buy a car, to put a deposit down on a house, to takes trips or to pay their own bills."
Diverting these assets can jeopardize the resident's Medicaid eligibility, McCracken said. Nursing home residents are required to "spend down" their own assets to pay for their nursing home care, and when their assets are exhausted Medicaid kicks in. Medicaid has a five year "look-back" period designed to prevent individuals from giving away their money and then going on Medicaid when they need a nursing home.
McCracken is a licensed nursing home administrator who spent 15 years in long-term care administration. He was previously chief executive of the House of the Good Shepherd, a continuing-care retirement community in Hackettstown, and before that spent 12 years as an executive with the United Methodist Homes of New Jersey.
"I already knew about the office of the ombudsman because New Jersey is a mandatory reporting state: all long term care providers must report incidents of abuse and exploitation to the office of the ombudsman as well as the department of health."
When he was running nursing homes, he would occasionally report cases to the ombudsman, and had investigators come out to talk to him. "Since I've assumed this position I've certainly learned a lot more about what the ombudsman does and it is not just complaint investigation." He said his office plays a positive role in improving the quality of long-term care in New Jersey, and the volunteer advocate program is a key initiative McCracken is pursuing to achieve that objective. "I always viewed my role as a long term care administrator as an advocate for the very vulnerable people I was working for," McCracken said. "When this opportunity presented itself I thought I had an opportunity to take my core mission for going into long term care administration and do it on a statewide level."
McCracken said the volunteer advocates, "are caregivers at heart, they are people who are very concerned about a very vulnerable population in nursing homes. They are mission driven people who want to make a difference, and they are making a difference." Some of the volunteers are retired, others are still employed, and they come from all walks of life.
Michele Kent, president of LeadingAge New Jersey, the association of nonprofit long-term care facilities, said the volunteer advocate program, "makes a lot of sense and they can do a wonderful job. But like any volunteer program, it is fair to say that it's as good as the training the volunteer is given."
Kent, who during the administration of Gov. Christie Whitman ran the Department of Human Services, which oversees Medicaid, said she appreciates McCracken's approach, which is to "be partners with our members and raise the bar for everyone for the quality of care. He approaches it from the point of view that we are on the same team."
Paul R. Langevin Jr., president of the Health Care Association of New Jersey, an association whose members are for profit nursing homes, said "we've had a very positive experience with McCracken's leadership to date. He has a history of working in long-term care and understanding all of the things that go into delivering care to people. He is fair, he doesn't jump to conclusions, he's been very willing to have conversations about things. He is truly an advocate for the individual resident. And advocating for the elderly residents in nursing facilities sometimes means that you are going to be at odds with the family." That can happen when there is possible misuse of a resident's money by a family members, and Langevin said McCracken is vigilant about pursuing these cases.
Jerry DeBenedette is a retired Prudential executive who has been a volunteer advocate for the past 14 years at Stratford Manor in West Orange. His advocacy has ranged from helping residents file income tax returns so they could receive the $350 federal stimulus payment in 2008, to helping a resident get a new roommate who shares his love of baseball.
"I am a strong believer in getting the residents to advocate for themselves," he said. "I try to help them with their concerns or complaints, and it can be a simple thing, like the curtain between beds is jammed and it cuts off the view of the outside." Sometimes a resident doesn't understand the medication schedule; he'll get a nurse to explain it. He'll bring complaints about meals to the head of the dietary department; he encourages residents to get out of their rooms and go to the dining room for meals, and to join in activities and entrainment.
He may drop in on a patient and notice the man hasn't been shaved; it may be that the resident refused a shave that morning, but DeBenedette will intervene so that it gets done. If he picks up on a conflict between a resident and an aide, he'll ask management to make a personnel switch.
Steven Salvanto, administrator of Stratford Manor, said DeBenedette "is a great intermediary. If there are any issues he comes right to me, and it keeps the communication open between the facility and the family and the resident so things are resolved before they turn into a really major issue. It gives residents a sense of security to have another person to go to who is not tied to the facility. People sometimes feel more comfortable approaching him. Then he will come to me and we'll get it resolved."
"I hate to say to this," said DeBenedette, "but there are some people that have nobody. They will say 'you are the only person I ever see besides the staff.' I talk to them about whatever they want to talk about. "