By David Hahklotubbe, gerontologist

Whew, you made it!  Welcome to the final installment of our “Noticer” series.  By now you are almost an expert on navigating long term care and are far more qualified to make an informed decision on placing a loved one.  We’ve uncovered some of the lesser-known “behind the scenes shenanigans that go on, now we are focusing our attention on who the more reliable sources of unbiased information comes from.  I will be rating these sources accordingly on a Likert scale from 1-5, 5 being the most reliable.

Right out of the gate, I want to dispel the myth that the governmental agencies that are responsible for enforcing compliance in long term care communities, assisted living specifically, are a good source of unbiased information and rating.  States, like California, have entities such as Community Care Licensing through their Department of Social Services.  On their website, they have attempted to go “full transparency” and you can read the history of any community’s audits, citations and complaints.  The issue with this is that we are left to assume that there is no internal bias, that the auditors are fair and well-trained and that the narratives are true and correct.  That assumption would be WRONG.  And, as a result, throws of the legitimacy of the site as a viable source of influential information when making a decision.

How do I know this?  Well, aside from operating in this field for nearly a quarter of a century, I’ve also worked closely with licensing, owned and operated large and small care homes and have good friends who have since retired from these agencies and have shared valued information with me.  First, I want to make it clear that while I am painting with a broad brush, not all evaluators and licensing program analysts are biased… now, that said, it’s been understood for decades that auditors are human and humans have bias.  Much of the bias is for good reason, but still does not have a place in performing accurate audits.  Many of the auditors favor the smaller care homes, the “mom and pop” 6-bed style and will literally verbalize their dislike of the larger for-profit hospitality-driven corporate giants.  This bias comes from the juxtaposition of the higher than average monthly rates the residents pay and the staffing levels and salaries for the care staff.  In their perception, the larger corporations over-charge clients and under-pay staff and commonly don’t have enough staff.  Now, while this may be true in some cases, they enter into these communities to perform their audits, with this in their minds and often it becomes a witch hunt.  Am I saying that the larger companies don’t deserve this bias?  No.  What I am saying is that the auditors go into these audits with a chip on their shoulder and regardless of whether the larger communities are exhibiting this behavior, they are rougher on them and tend to cite them more often.

I have owned two smaller homes for 20 years and have amassed 1/150^th the amount of citations of the larger ones that I have operated over my career.  When running the larger ones, I replicated the same program design, same staffing levels, roughly the same rates of pay from my smaller homes, and yet, magically, more citations.  To make it worse, when I did not “get along” with the personality of the auditor, the way in which the citations were written were very different – vindictive and personal.  You can ask any operator, large or small, their opinions on the average licensing program analyst and they will likely agree that they are poorly trained, opinionated and intoxicated by the amount of power they are given.  I have seen some outrageous behavior from these folks and when I retire, will be releasing a tell-all volume of books what will include some of these outrageous experiences.  But, for now, take my word for it, you cannot and should not consider these agencies as reliable sources to base your decision upon.  But, if I haven’t been effective in convincing you…. You’ll like this story….

Another reason why you should not rely upon these agencies is that, like with the reputation sites we spoke of in the last installment, the industry has figured out how to manipulate this situation.  A good chunk of my career was going into troubled and challenged communities and turning them around.  On par, I once worked for a larger company that was completely dysfunctional and had the licensing rap sheet to prove it.  As shady operators do, they found a loophole in the system.  The licensing reports are specific to the operator’s license.  While it is a significant undertaking to change the facility license and re-name it, it is well worth escaping the legacy of a permanent and damaging record.  And, that is exactly what they did.  Their reputation, at least as far as the licensing website was concerned, was completely wiped out and they pushed reset by simply changing their name and getting a new license.  The casual observer of the website would not take notice of the fact that their years of operation were far less than those of us who have stayed with our original license for 20 years.  I rate governmental agencies as a 1.5 for this reason.

Alright, I’m sure you’re saying by now, “Hey David, you’ve been brilliant in telling us where NOT to search – how about laying some knowledge about where to search?”  And, you’d be right – switching gears… here we go.

Most states have an entity that is routinely in and out of care facilities and has no skin in the game.  They are volunteer-based and called the “Long Term Care Ombudsman”.  While their official position is that they don’t (can’t) make recommendations on where to place your loved one, they have a finger on the pulse of who is who and are a valuable resource.  An insider tip is that if you entertain a conversation with a representative long enough and get them comfortable enough, they will share their personal opinions.  Again their official position is that they don’t have a ranking system.  They do.  I’ve literally seen it myself.  I’ve been a trainer for the Ombudsman program for over 20 years and I teach their staff how to manage difficult behaviors related to sexuality and dementia, given my degrees.  I have literally held the coveted ranking list in my hands.  It is a simple system, it’s a printed list of all facilities with some highlighted with a fluorescent marker, some left alone and some…. with a strike-through.  If you get into the circle of trust with the person on the phone, they will share this information with you – they are on your side.  And, I have to say, when I studied the list, I agreed 100%.  I rate them a solid 5.

Ok, we are on a roll.  Let’s stay on this path.  While you will rarely, if ever (never) get an accurate referral from an in-home care provider (conflict of interest), you CAN inquire with a Geriatric Case Manager.  While a component of their services is in-home care, they are also well-versed in long term care placement and are not funded by the providers.  They also tend to be educated in the field of gerontology or at least something close, whereas the in-home care industry is chocked full of people who are from collapsing industries and saw income potential over improving quality of life.  Fact check me – if you have time to kill, call a few providers and ask what their degrees are in.  At best, you will get the predictable dodge to the question.  I rate Geriatric Case Managers a solid 5.

Hospital or Skilled Nursing discharge planners.  Hmmm this one is rough.  And only because things have changed so much over recent years.  These folks used to wear a halo – they had a list of providers and took time to find the right placement.  They stood alongside the ombudsman as being extremely well-educated.  For instance, they noted patients who were routinely coming in for dehydration, skin breakdown or urinary tract infections and where they were living.  They would divulge where they would place their loved ones based on this clinical data.  HOWEVER, many (most) have been silenced by greed.  Placement agencies have infiltrated this population in two ways.  1. They have offered to step in and perform one of their main tasks, finding quality care for their discharging patients.  2.  They pay them (in creative ways) to do their job.  Who can say no, when you are making a meager salary?  What this has done is made the discharge planner complacent and nearly inaccessible.  The discharge planner now, is nothing more than a conduit to the placement agencies and doesn’t really have a finger on the pulse of which local provider is the best.  Fact check me… ask the discharge planner about a specific local provider.  If they are even familiar with the provider, ask if they have ever been to the facility.  I know I’m right.  15 years ago, I would have rated them a solid 4, today, I rate them a low 2.

Second to the discharge planners are the various doctor’s offices.  Depending upon the nature of the practitioner and their discipline, you will get a mixed bag of advice.  The sad reality of the medical field is that it is assumed that just because you are a practitioner, you have a broad base of knowledge of all other providers and disciplines.  This is definitely NOT true.  Most practitioners have zero knowledge of long term care and will most likely recommend the medical model – skilled nursing facilities, aka nursing homes.  Here are a few folks that I would likely trust….. Geriatricians, Neurologists, Urologists, Dermatologists, Physical Therapists and Occupational Therapists.  They see the geriatric patient and know where they reside.  The least they can provide is an opinion of what they have seen from various providers.  For instance, if they see routine issues of skin breakdown that has not been managed well, that goes into the data bank in their memory.  I rate them a solid 4.

I round out my list with what may seem as obvious…. The horse’s mouth.  Visit communities that you are considering, and get friendly with the staff and the residents.  Believe me when I say that both populations will be more than happy to share their opinions.  Take notes.  When you are asking questions, be sure to keep in mind what are tangibles and intangibles for your specific loved one.  For instance, if food is a hot button (when isn’t is?), ask residents about the food.  Ask staff if they eat at the facility.  Be clever.  Is this an easy journey?  No.  Is the work that you put into it congruent with what you are going to yield as far as results go?  Yes.  Mobilize, be smart, take my advice and as a thank you for my free assistance, circle back and share your results and discovery so that I can update my BLOGS.  I’ll leave you with one last thing…. Luck is garbage.  You are squarely responsible for the outcome of anything you undertake.  The more information and knowledge you have going into a situation will increase a favorable outcome, not a mysterious third-party fluctuating influence.  If you are like most and employ luck to be your guide for finding the best possible fit for your loved one, you will fail. Ensure your outcome by performing due diligence.  That all said, at this stage, I wish you happy hunting, not good luck.

Love, David