By Thomas Vincz, Public Relations Manager

It was supposed to be a quiet Friday afternoon for one New Jersey nursing home tenant. But then, out of nowhere, the resident was told by the facility’s management that he needed to leave, even though they had no discharge plan for him beyond the exit door.

The resident, who was also a Horizon Blue Cross Blue Shield of New Jersey member, was enrolled in the New Jersey Medicaid program called Managed Long Term Services and Supports (MLTSS), a federal program meant to help members with chronic conditions live independently and safely in their own communities. As one of the managed care companies (MCOs) chosen by the State to serve Medicaid beneficiaries, Horizon places nurses and social workers in the role of personal care managers to implement MLTSS for their patients.

Happily, the resident had some back-up for his unplanned discharge. First, the intervention of a Horizon MLTSS Member Advocate. And then the support from a powerful advocate allied with Horizon: New Jersey’s Long-Term Care Ombudsman (LTCO).

The LTCO, as part of New Jersey State government, handles complaints about the rights and welfare of residents of long-term care facilities who are age 60 or older. At times, the LTCO’s views can differ from a health insurer’s when it comes to the appropriate level or location for care these residents should receive.

However, the LTCO and Horizon BCBSNJ, have developed a trusted relationship based on a shared sense of mission.

“MLTSS is all about making sure members are safe and have the services and supports in place to meet their needs,” said Sue Bailey, one of three Horizon MLTSS Member Advocates. MLTSS Member Advocates work in coordination, but separately from, the personal care managers. “It was clear that this member’s health was at risk. Fortunately, we have developed a relationship where we can call the Long-Term Care Ombudsman for further assistance in such cases.”

This trust flows both ways between Horizon and the LTCO. “Our office is 100 percent resident-focused,” explained Laurie Brewer, New Jersey’s LTCO. “Everybody has their job to do in the long-term care world, and our only job is to advocate for that resident. When Sue [from Horizon] calls, I know it’s because she understands that we are uniquely positioned to intervene on behalf of the resident in question.”

In the case of this particular questionable discharge, the Ombudsman’s Office sprang into action to fight for the resident’s rights.

“Our General Counsel is second to none in knowing how to deal with these last-minute issues, so we’re able to buy some time, slow the discharge process down and make sure everything has been done to assist the resident,” Brewer said.

This pause proved valuable. “The extra time that Horizon gets as a result of the Ombudsman’s intervention allows us to make sure a discharge is managed in a fair and organized way,” added Carol Cianfrone, Director of MLTSS Clinical Operations for Horizon. “And we’re much better positioned to set up and activate a new community-based living arrangement that is customized to the MLTSS member’s specific needs.” Services for an MLTSS member can include personal care, transportation, home delivered meals, and behavior health and addiction services.

Common ground, common purpose

Brewer, the State’s Ombudsman, attributes the synergy her office has developed with Horizon in large part to Bailey’s previous experience working for the Office of the Public Guardian, an arm of the NJ Department of Human Services devoted to protecting senior, incapacitated residents.

“Because Sue comes from a public sector background of advocacy, she understands what the LTCO is trying to accomplish,” said Brewer.

When Bailey arrived at Horizon in 2014, the MLTSS program was just getting off the ground. She immediately recognized the importance of developing a collaborative relationship with the LTCO.

“There was initial concern with MLTSS that managed care organizations might start pushing people out of institutional environments, like nursing homes, which tend to be the most expensive modality of care,” Brewer added. “In fact, based on the calls to our office, we have not seen a wholesale push of people into the community without the services and supports they need, and that’s a good thing.”

As evidence for how a public/private partnership in resident advocacy can work, Brewer, Bailey and Cianfrone recently traveled together to Virginia to participate in a national conference hosted by the National Consumer Voice for Quality Long-Term Care, the largest long-term care consumer advocacy organization in the country.

There, they made a joint presentation to ombudsman officials and advocates from across the country, stressing the benefits of close and health working relationships among the public and private organizations who fill parallel roles in caring for MLTSS members.

“As I said at the conference,” Brewer explained, “one of my priorities in this new year is to outreach and in-service the other MCOs to try to create the same kind of relationship with their member advocates that I have with Sue and Carol. It’s to the benefit of the residents and, at the end of the day, that’s what it’s all about.”

Read more about New Jersey's Long-Term Care Ombudsman here.