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Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act (1995)

Chapter: Effectiveness of the State Long-Term Care Ombudsman Programs

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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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5
Effectiveness of the State Long-Term Care Ombudsman Programs

INTRODUCTION

The history and practical experience of program evaluation research indicate that the extent to which a program is working can be elusive when precise data on program outcomes are not available. The struggle this Institute of Medicine (IOM) committee encountered in assessing the effectiveness of the state long-term care (LTC) ombudsman program was due primarily to a lack of uniform data (on both processes and outcomes) across states and sites. The challenge was further complicated by little theoretical consensus regarding appropriate effectiveness measures and a “fragmented mosaic” of empirical and evaluative research on the program (H.W.Nelson, Office of the LTC Ombudsman, Oregon, personal communication, February 1994).

Nevertheless, the committee regarded it as imperative to attempt some formal evaluation in line with its official charge. The evaluation strategy it adopted is briefly explained in the next section. Because it was not possible for the committee to make definitive pronouncements about the effectiveness (or lack thereof) of the current ombudsman program, it chose instead to offer criteria and indicators by which the national program, or individual state programs, might begin a comprehensive process of self-examination. These criteria are presented in the form of a series of tables describing essential and unacceptable practices (see “Models of Implementation,” below). These tables provide a means of establishing standards and benchmarks that may be used in future evaluations when systematic data are more readily available.

Therefore, selected findings are presented, drawn from many different sources to describe the functioning and apparent effectiveness of the ombudsman program in terms of its ability to (a) communicate an awareness of its existence

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

to residents and community, (b) investigate and resolve complaints, (c) convince providers and state unit on aging (SUA) directors of the program’s usefulness, and (d) manage human (volunteer) resources. These findings do not necessarily provide unequivocal evidence of program effectiveness. Rather, they suggest the program is very likely attaining several of its goals in selected areas and in selected locations. Hence, they provide the basis for the formative nature of this evaluation and the nature of the committee’s recommendations. The chapter ends with a series of recommendations intended to improve the capacity of the national and the state programs. Specifically, after recommending that Congress continue the program and that the federal government implement an objective method of compliance review, the committee recommends five ways the program’s data collection and information system can be improved. One recommendation is made to enhance the management of volunteers.

EVALUATION CONTEXT

Evaluation Strategy: Formative and Summative Evaluations

Although the ombudsman program has been in varying stages of implementation over the past 20 years, ombudsmen themselves, researchers who have studied various aspects of the program, and experts who served on the committee concur that the program has not stabilized or achieved complete implementation in all states. Further, in those states where it has been fully implemented, data on program effectiveness are often imprecise and far from comprehensive. These realities led the committee to adopt a formative evaluation strategy.

Formative evaluation is geared toward improving program performance by providing feedback on substantive operational dimensions of the program (Scriven, 1991). It suggests a framework for ways to improve processes and data, including ways to provide data useful for assessing effectiveness. Formative evaluation can point the way to hypotheses that may be tested in a later summative evaluation. Because its goal is to assist in producing positive changes to improve the functioning and data reporting system of a program (Stadish et al., 1991), formative evaluation is more appropriate to the ombudsman program than a summative evaluation would be.

Summative evaluations judge program worth by assessing program effects or impacts. They are appropriate when a program is fully implemented and evidence of stabilization and institutionalization (e.g., adequate infrastructure and full implementation) can be found. The committee recognized that, given the state of the data, the state of the field, and the variability in stages of program implementation across the states, a summative evaluation of this sort was not appropriate.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

The committee’s approach accords with Carol Weiss’ (1972) suggestion that efforts to develop effective social policies and programs have suffered from too much summative evaluation of ill-conceived interventions and too little research into the causes of social problems and the obstacles to their solution. Consequently, the specific purpose of the IOM review is to investigate some evidence regarding the effectiveness or ineffectiveness of the ombudsman program while it is still evolving, in order to facilitate decision making and improve program management. Thus, in addition to attempting to shed some light on the larger question of what difference the program makes, the committee’s primary goal has been to encourage positive program changes and improvements that are needed in view of evidence available to date in the lives of individual residents of LTC facilities and at the system level.

Effectiveness Questions

Effectiveness, for purposes of this report, means that the objectives of the LTC ombudsman program, as specified in the Older Americans Act (OAA) and its various amendments, are met to the maximum extent possible. It means that services are provided to residents and that residents, their families, and other advocates are informed as to the availability of those services. Furthermore, the effective ombudsman represents the interests of the residents in both quality of care and quality of life—first, last, and always—before the interests of governmental agencies and seeks administrative, legal, and other remedies to protect the health, safety, welfare, and rights of the residents of LTC facilities.

Measuring effectiveness raises two fundamental questions: Does the ombudsman program resolve the problems that confront residents of nursing facilities and board and care (B&C) facilities, with respect to the quality of their lives and their rights or privileges (when they exist)? Are individual residents and their families satisfied with problem resolution and systemic changes that affect the quality of residents’ lives in these facilities?

In this context, effectiveness evaluation should obtain systematic and consistent information on the impact of the ombudsman program on public policy and provider behavior and on the extent to which changes in policy and provider behavior benefit consumers or recipients of LTC. More specifically, this effort should seek to answer the following kinds of questions: (a) Do residents have access in a timely fashion to an independent ombudsman who can help them, especially in resolving complaints they may have against LTC facilities or staffs? (b) Do residents, families, and other citizens know about the ombudsman program, and can and do they use it? (c) Do LTC providers know about and support the program? (d) Does the program assist SUAs in accomplishing their mission? (e) Are state and local LTC policy directives implemented as a result of program initiatives?

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

In other words, residents, providers, and others must be aware of the ombudsman program and have access to it, and an adequately funded and organized system must be in place to address the problems of LTC residents and to improve the quality of their care and lives. Basic access and capacity at the state and local level, as well as adequate oversight and support at the national level, are necessary but not sufficient conditions for effectiveness.

In examining effectiveness the committee considered several key prerequisites. These included: (a) the organizational infrastructure of the ombudsman program; (b) inputs to and resources for the program, such as the enabling legislation, financial and staffing resources, databases, and information systems; (c) processes and selected types of outputs, including ways of handling complaints and coordination with agencies involved in quality assurance; and (d) selected outcomes such as resolved complaints, resident satisfaction, and system change attributable in whole or in part to the program. The discussion on compliance in Chapter 3 is obviously relevant to the data review in the context of effectiveness; the compliance discussion focused chiefly on whether certain activities occurred but stopped short of assessing what were the outcomes of such activities.

Because federal and state policy and other environmental factors are changing in myriad ways—including the sweeping restructuring of the health care industry in the past decade and into the present—effectiveness must necessarily occur in the context of our evolving health care and social system. Changes in acute and LTC delivery and health care policy highlight both the growing importance of the ombudsman program (see Chapters 7 and 8) and the need to regularly monitor the effectiveness of the ombudsman program as it responds to changing conditions and new challenges.

Data and Information Sources

The committee’s approach embraced two elements of research: triangulation and a variant of meta-analysis. “Triangulation” denotes the utilization of similar or complementary data from a number of sources to verify or validate program findings. Although the committee did not combine and reanalyze data, the committee applied a meta-analytic approach in the sense that it examined, compared, and analyzed previous qualitative and quantitative research findings on program effectiveness from multiple data sources.

Given the variability and lack of comparability in available 50-state data, the committee concluded that a comprehensive statistical approach to obtaining

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

information on effectiveness across the states1 was possible only for a limited number of variables. This approach was possible primarily for the “success” variables included in a recent study from the Office of the Inspector General of the Department of Health and Human Services (OIG, 1991a,b,c). The commissioned papers for the IOM study and surveys and interviews conducted by IOM staff, consultants, and committee members contributed new analyses and additional sources of information from state and local ombudsmen, SUAs, providers (e.g., nursing facility operators and medical directors), and advocacy groups (Chaitovitz, 1994a,b; Elon, 1994; Holstein, 1994; Hornbostel, 1994; Huber, 1994; Kautz, 1994; Lower, 1994; Lusky et al., 1994; NCCNHR, 1994; Phillips et al., 1994). Committee members and staff examined and reanalyzed many available data sources, searched the literature, conducted site visits, and held a national conference and hearings on effectiveness. Each step provided new information relevant to study questions on effectiveness.

This triangulated approach to data collection and analysis forms the basis of the committee’s assessment of program effectiveness. It relies on qualitative and quantitative data and represents a variation on meta-analysis in dealing with the multiple dimensions of effectiveness. The committee’s assessment is a collective product of the individual interpretations and expert opinions of the different committee members, who represent a range of professions and disciplines knowledgeable in LTC issues and who brought their informed judgment to bear on a variety of topics related to program effectiveness.

With respect to previous work on evaluation, the committee is indebted to the efforts by the ombudsmen themselves in developing monitoring and evaluation tools.2 The evaluations of the General Accounting Office (GAO, 1992b) and the OIG further contributed to the committee’s understanding of the complexities in conceptualizing and utilizing indicators of “quality” performance.

Quality as a Central Issue in Effectiveness

Although the ombudsman program is not directly responsible for assessing, assuring, or improving the quality of LTC services provided in LTC facilities,

1  

An analysis of reliable and valid data across all states is essential to a full national “program” evaluation, in contrast to a specific individual state or local “project” evaluation (see Wholey et al, 1971).

2  

Materials the committee found useful included: A Menu for Excellence: A Guide to Program Evaluation for the State Long-Term Care Ombudsman Program, from the National Eldercare Institute on Elder Abuse and State LTC Ombudsman Services (1993a); and Toward Quality Long-Term Care Ombudsman Programs, from the National Center for State LTC Ombudsman Resources (1991).

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

it can be assumed to have filled a niche related to LTC quality assurance through a consumer-oriented advocacy mechanism (see for example IOM, 1986; Kane and Kane, 1987; Cherry, 1991, 1993; Arcus, 1994; Holstein, 1994; Nelson, in press; Nelson et al., in progress). Under this assumption, the variation inherent in ombudsman programs at the state and local level can be expected to result in differential influences on the quality of services provided to residents of LTC facilities. Variation exists partly because the OAA permits each state leeway in many aspects of the ombudsman program—for example, in deciding (a) where ombudsman programs may be located within the state, (b) whether enabling legislation should be passed, (c) whether additional funding will be made available through state and local match, (d) whether the use of volunteers will be encouraged or forbidden, and (e) how advocacy will be enhanced or impeded by interpretation of conflict of interest laws. Those differences mean that the quality, or likely effectiveness, of the ombudsman programs can be expected to vary across the nation. Consequently, the quality of the LTC services provided to residents of nursing facilities and B&C homes will also vary by state and within states.

In addressing the effectiveness of the ombudsman program, the committee set out to understand and assess effectiveness within the parameters of what is possible and what is desirable for the program to achieve. Central to the question of effectiveness is the complex issue of program quality, for which no all-encompassing, easily measured definition exists.

Even though consensus is lacking regarding measures for determining program quality, this does not in itself point to a lack of efficacy in the ombudsman programs. There is no single best way to measure the impact of end results of large-scale programs, especially federal programs mandated to be carried out at the state level. The committee’s approach was to take the information as a whole and determine, to the extent possible, whether the ombudsman program appears to make a difference in terms of quality of life and quality of care in LTC facilities, or in terms of changes at the systemwide level.

Political and Environmental Factors Relevant to Effectiveness

In assessing the effectiveness of the ombudsman program, it is essential to acknowledge that the program operates within political and resource constraints that limit the scope of what it can accomplish. Unto themselves, these limitations should not be considered as evidence of the program’s ineffectiveness.

At least five contextual factors are relevant in this regard:

  1. interest groups within the political process that are antagonistic toward the ombudsman program;

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×
  1. the bureaucratic nature of most of the institutions within which the ombudsman program must work;

  2. financial and organizational disincentives that impinge on the level and quality of medical care, nursing services, social work, physical and occupational therapy, and activity therapy provided by facilities;

  3. socioeconomic or cultural conflicts among residents or between providers and residents; and

  4. difficulties resulting from such physical design features of LTC facilities as limited space or unattractive or inefficient physical layout.

The ombudsmen can try to ameliorate these situations but most likely cannot eliminate them because they reflect the larger societal context.

MODELS OF IMPLEMENTATION AND MEASURES OF EFFECTIVENESS

Infrastructure and Function

The mission of the LTC ombudsman program as outlined in the OAA is noble but extremely demanding. It requires attention to millions of individuals across the country who live in a range of settings, from single-family homes involving one owner/caregiver to mammoth buildings with a thousand or more residents and employees. The OAA calls upon ombudsmen to address, with a friendly, informed, and competent demeanor, the concerns of millions of consumers, as well as to respond, with skillful analysis, to the dynamic public policy issue of a multibillion-dollar health care system.

The ability of the LTC ombudsman program on a national level to perform its duties and responsibilities in varied arenas depends largely on a clearly stated mission supported by commensurate funding and oversight by the Administration on Aging (AoA). The necessary financial resources to produce a program that meets the congressional mission and the elements outlined here are discussed in Chapter 6. This chapter, in effect, deals with matters central to AoA management responsibilities.

Tables found at the end of this chapter (Tables 5.2 through 5.9) present the key elements of infrastructure and function that the committee believed were central to an effective program. This formulation is a culmination of the committee’s study and discussion of how the program should be structured, organized, and operated to fulfill its mission as stated in the OAA. In developing this framework, the committee referred to OAA provisions related to duties and responsibilities of both the state and local ombudsman programs. The necessary infrastructural and functional elements of an effective ombudsman program in every state are described in the following categories:

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×
  • Table 5.2: Structure of the Office of the State LTC Ombudsman and Elements of the Host Agency(s) for the State and Local Entities

  • Table 5.3: Qualifications of Representatives of the Office;

  • Table 5.4: Legal Authority;

  • Tables 5.5a through 5.5d: Resources (financial, information management, legal, and human);

  • Table 5.6: Office of the State LTC Ombudsman Program;

  • Table 5.7: Individual Resident Advocacy Services;

  • Table 5.8: Systemic Advocacy Work; and

  • Table 5.9: Educational Services.

The committee reached consensus on a set of concepts and terms relating to superior, basic, and substandard performance. Specifically, it uses the terms “exemplary practices,” “essential practices,” and “unacceptable practices.” The tables contain (a) the contents of necessary infrastructure, inputs, or prerequisites and (b) the resulting functions, outputs, or products of an ombudsman program in each of these three categories, which are briefly defined below.

Exemplary practices represent a composite of the most successful elements that presently exist in some state or local programs and to which such programs aspire (or ought to aspire). The achievement of exemplary practices necessitates that all essential practices be in place and be reflected in the activity and performance of the state’s program as a whole. The committee did not search for nor did it find any program that contained every element of exemplary practice.

Essential practices are described based largely on a focused reading of the OAA to determine the basic or minimum requirements for a state’s ombudsman program. Thus, they consist mainly of the elements necessary to comply with the OAA. As discussed in Chapter 3, the AoA has provided little guidance to the states on essential practices in recent years. As a direct result, there are a variety of ways to meet the mission of the program. However, all requirements in this section of each table must be met in order for the program to be effective.

Unacceptable practices describe elements and practices that clearly do not conform with the mission of the program as envisioned by Congress. These practices exist and have been found in a number of states that have posed obstacles to the ability of LTC residents to receive comprehensive and, in some cases, any ombudsman services promised them in the OAA. These unacceptable practices are not hard to find across the country. Some in the aging community and some ombudsmen publicly state that some such practices are acceptable in their view. However, the committee finds these practices unacceptable and antithetical to the mission of program, and it takes the position that AoA, SUAs, ombudsmen, and all advocates for LTC facility residents ought to work aggressively to eliminate them.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Some of the terms and phrases in Tables 5.2 through 5.9 refer to more detailed concepts or requirements. They are defined as follows:

  • Office of the State LTC Ombudsman or the program refers to a state’s entire program, whether it uses wholly paid staff or some combination of staff and volunteers and whether it is housed within or outside of a state agency.

  • Prohibited ties and conflicts of interest refer to those conflicts of interest prohibited by the OAA. These were discussed more fully in Chapter 4.

  • LTC facility means all those facilities defined under the OAA as ones for which the ombudsman program has responsibilities (i.e., nursing facilities, B&C facilities including those termed assisted living or congregate housing facilities, and other similar residential homes).

  • Representative means a person designated to perform ombudsman services as outlined in the OAA. This includes the state ombudsman, state ombudsman staff, regional or local paid ombudsman staff, and volunteers. All representatives of any Office of the State LTC Ombudsman are subject to a designation process before they can conduct any ombudsman functions.

  • Designation (or de-designation) process refers to the authority given to the state ombudsman to appoint representatives (as defined above) of both the office and any local entities (e.g., agencies, organizations, etc.) that house representatives of the office. All such representatives are subject to a procedure that involves training, competence evaluation before conducting ombudsman functions, and conflict of interest examinations of entities with whom the representatives are affiliated.

  • Suitable access means access to facilities, residents, and records for the ombudsman program as provided for in the OAA and in federal nursing facility reform law (the Omnibus Budget Reconciliation Act of 1987). It involves issues such as timeliness of response by facilities to inquiries or requests made by the ombudsman, amount of access, and ability to copy records.3

3  

Access for ombudsman to facilities, residents, and records is not the same as that for regulatory agencies or others. Under federal law (both the Nursing Home Reform legislation and OAA), ombudsmen are to have the ability to enter LTC facilities in order to meet with residents and evaluate their concerns. The access to facilities is not unfettered, however, because federal law does not call on ombudsmen to go into places within a facility that residents cannot enter (such as areas set aside for use exclusively by staff). Similarly, ombudsman access to residents is not unfettered. The ability of ombudsmen to talk with any resident is limited by the resident’s permission, and federal law allows any resident to end any face-to-face visit with any ombudsman. Access to two basic types of records is envisioned: records held by regulatory agencies about particular facilities (a reaffirmation of the protections of federal and state freedom of information acts) and records held by an individual facility that pertain to an individual resident. With one exception, ombudsmen cannot access individual resident records without a resident’s

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×
  • Sharing ombudsman data with residents, families, or others does not mean that the committee envisions or recommends that the program become a rating or ranking program for LTC facilities. Each state’s program must evaluate whether its internal data on concerns, problems, and issues from individual residents about particular LTC facilities can and should be shared with the public. Factors to consider are: the reliability of the data in terms of accurately portraying life in a home or comparing quality of life for residents of different homes; the program’s capacity to maintain and share the data with all who inquire; other sources of information (survey and complaint investigation data from licensing and certification agencies); the confidentiality provisions of the OAA; how providers will react to the publication of internal complaint data; and how the nature of individual resident advocacy services and systemic advocacy work might change with public disclosure of facility-specific information.

In presenting these tables on exemplary, essential, and unacceptable practices, the committee is attempting to do several things. First, it wishes to articulate, by this means, useful guidelines or standards for ombudsman programs, including what the committee perceives to be ideal characteristics of effective programs. Second, the committee recognizes that the various ombudsman programs, understandably, differ in infrastructure and function, and that no one program will be exemplary in all elements. In constructing this set of practices, therefore, the committee hopes to challenge all programs to reach new levels of effectiveness and service to the nation’s residents of LTC facilities. These ideal practices are revisited in articulating recommendations at the end of this chapter.

Performance Indicators

Table 5.1 presents a listing of examples of important performance indicators, categorized into three levels: individual, facility, and system. Ideally, empirical evidence should exist demonstrating associations between the infrastructure and function practices set forth in Tables 5.25.9 and the performance indicators in Table 5.1. However, as noted earlier, the lack of uniform data on both processes and outcomes across states and program sites precludes analysis to estimate such

   

permission or the permission of the resident’s legal surrogate. The OAA provides that, when a legal guardian refuses to give the ombudsman permission to look at resident records in a situation in which the ombudsman believes that the guardian is not acting in the resident’s best interests, the ombudsman can look at resident records without the resident’s or guardian’s permission. The OAA requires that the state ombudsman approve such an examination.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

correlations or associations. The majority of evaluations that have looked at the issue of effectiveness in the ombudsman program address outcomes at the individual level. Few address indicators of system-level effectiveness, and even fewer explicitly address indicators of facility-level effectiveness.

At the individual level, performance indicators generally pertain to improvements in the quality of life for residents. They involve such matters as complaints (resolved and unresolved), resident restraint reduction, resident sense of empowerment, protection of resident rights, and nutrition and hydration.

Facility performance indicators include improvements in such domains as the organization of services, environmental safety, and food. Achieving effectiveness with regard to facility-level indicators may require changing organizational culture necessary to bring about facility-level changes that render possible positive individual-level outcomes and to ensure that gains for the individual are not diluted or lost over time.

At the system level, indicators of effectiveness include awareness of the ombudsman program by facility, staff, residents, and others; increased resources on behalf of residents; and legislative and regulatory changes that improve the quality of care and quality of life for residents of LTC facilities.

Where indicators of effectiveness are documented, issues of attribution of the “cause” of these positive changes warrant further attention by researchers and evaluators. Two types of attribution are possible: direct and indirect. Direct attribution to the ombudsman program occurs when analysts can demonstrate that an outcome results directly from program input(s). Indirect attribution occurs when outcomes result from the influence of multiple sources, including ombudsman program interventions. The concept of indirect attribution acknowledges the fact that outcomes, particularly those on the system level, often result from the efforts of multiple parties. This is similar to the notion of role complementarily advanced by Cherry (1993) in describing the contribution of the ombudsman program in partnership with others in improving nursing facility quality.

EFFECTIVENESS OF THE OMBUDSMAN PROGRAM: THE DATA

Most analyses of the efficacy of the LTC ombudsman programs occurred in single-state studies (Cherry, 1991, 1993; Nelson, in press; Nelson et al., in progress). Other recent studies have looked at elements of the program across all or a subgroup of states, but such studies have not purported to be comprehensive evaluations (OIG, 1991a,b,c; GAO, 1992b; AoA/OIG, 1993; Huber, 1994). The AoA has not conducted a national program evaluation, and, in the 1980s, conducted only limited monitoring activities of any kind. Thus, although descriptive data on each of 52 state ombudsmen programs were

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.1 Examples of Performance Indicators for Ombudsman Programs, Three Domains

Individual Resident Outcomes: Quality of Life Improvements

• Complaint resolution

• Resident restraint reduction

• Resident sense of empowerment

• Protection of resident rights

—Retention of “home”

—Choice of roommate

—Retention of personal property

• Conflict resolution

• Comfort

• Nutrition and hydration

• Resolution of financial exploitation

• Companionship and social interaction—ombudsman visiting process

Facility Outcomes: Facility-Level Quality Improvements

• Changes in organization of services

• Environmental safety

• Meal services scheduling, presentation, and content

• Changes in organizational culture

System Outcomes: Quality of Life Improvements

• Awareness on the part of facility and staff concerning ombudman’s mission to identify and resolve conflict

• Awareness on the part of family, relatives, and friends concerning ombudsman’s mission (when family and friends are sources of complaints)

• Increased resources for residents (e.g., increase in personal needs allowance)

• Increased resources for program

• Reduction in Medicaid discrimination

• Legislation

• Regulatory change

• Moving from case to cause to correction

• Development and support of resident and family councils

• Increased community awareness

• Facility closure and receivership, when needed

• Positive interaction with facility staff

• Establishment of organizational, interorganizational, and associational mechanisms to identify, inform, and resolve problems

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

available to the committee, data elements relating to effectiveness were based largely on perceptions and informed judgments. The data serve, however, as examples of performance indicators and, although not ideal, contribute to the growing body of anecdotal and empirical information about the contributions ombudsman programs are making to improve the quality of life of residents of LTC facilities.

For purposes of reviewing information and data in light of what is indicated about the effectiveness of the programs, four broad categories of performance are described below, and the salient research findings are reviewed. This section also reports on the barriers to effectiveness that were identified by state and local ombudsmen during the course of the committee’s work.

Findings Related to Effectiveness

Build Visibility and Awareness of the Program

Programs are evaluated in terms of two related but distinct measures of effectiveness. The first, visibility, was utilized by the OIG and is measured by the annual frequency of visits to facilities, the ratio of professional staff to facility beds, and the ratio of volunteers to facility beds (OIG, 1991b). The second, awareness of the program, is measured by information on who files complaints, such as facility staff or family and friends (Huber, 1994; Phillips et al., 1994).

Research on the effectiveness of the ombudsman program indicates that the presence of ombudsmen increases abuse reporting, generating what researchers have called a “sentinel effect,” and increases facility accountability (Monk and Kaye, 1982a). Litwin and Monk (1987) report that facilities with assigned ombudsmen reported complaints at a substantially higher rate. Ombudsmen also have been shown to play an unintended therapeutic role resulting in “less tangible but nevertheless significant aspects of day-to-day life in LTC facilities” (Litwin and Monk, 1987, p. 102). The investigators concluded that residents who used program services were satisfied with the effectiveness of program interventions.

Although statistical analysis was not part of the inspection, the OIG study (1991a,b,c) showed that, among state programs that use volunteers, those with more volunteers paid more visits to LTC facilities and filed and resolved more complaints. State programs that were visible used both paid staff and an extensive volunteer program, frequently visited facilities, expeditiously handled complaints, publicized the programs, obtained “adequate” funding, and effectively recruited, trained, and retained volunteers.

More recent information generated as part of the IOM study has similarly documented the positive association between the frequency of visits and the

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

number of complaints reported across all states (Chaitovitz, 1994b; Huber, 1994; Kautz, 1994). (See also Netting and Hinds, 1984, 1989; Netting et al., 1992.)

Ombudsman visitation to LTC facilities is a major prerequisite of program visibility. Chaitovitz (1994b) analyzed the number of visits by LTC ombudsmen for a canvass of 50 states commissioned by the committee. Her findings indicate that visitation rates were influenced by such factors as whether states had local programs, whether certain facilities had higher rates of complaints, and whether LTC facilities were located in rural areas where scarcity of volunteers was more common. Interestingly, 72 percent of state ombudsmen did not consider the quantity of visits adequate, noting in particular concerns about the low frequency of visits to B&C facilities. Almost half (46 percent) of state ombudsmen would have preferred either weekly or biweekly visits to all LTC facilities, but they cited the lack of staff resources as the major deterrent to more frequent visitation patterns. More funding, it was implied, would have resulted in more professional staff who could have visited or trained volunteers to visit. Not surprisingly, staffing levels were reported as highly associated with visitation rates.

Two lines of research and evaluation merit further attention with regard to visibility and awareness. First, the concept of the ombudsman’s “sentinel” or “deterrent” effect should be more carefully considered (Monk and Kaye, 1982a; Monk, Kaye, and Litwin, 1984; Litwin and Monk, 1987; Cherry, 1991, 1993; Nelson, 1993; Nelson, in press; Nelson et al., in progress). The committee expressed concern regarding the need for better measurement of the ombudsman’s role in creating a deterrent or sentinel effect. Although many studies claim the existence of such a deterrent effect, specific research is needed to substantiate and demonstrate the causality of explicit outcomes that result from the presence of ombudsmen. Second, the relationship between measures of visibility and awareness must be investigated more fully, incorporating the three levels of analysis (individual, facility, and systems) described in the previous section on effectiveness indicators.

Investigate and Resolve Complaints

The identification, investigation, and resolution of complaints is directly related to the outcome measures of improvement in the quality of life for residents. Even though process data suffer from extreme program variability with regard to the meaning of terms used in describing complaints filed, investigated, and resolved (GAO, 1992b), these data can still be informative. As was noted in Chapter 2, the total number of complaints received by ombudsmen almost doubled over the five-year span from 1988 to 1993. Complaint resolution rates have also improved, increasing from 65 percent in 1987 to 74 percent in 1992 (AoA, 1993).

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Huber (1994) analyzed complaint reporting and resolution from ten state ombudsman programs. Findings from this research, using complaint-specific data as an indicator of performance, show that ombudsmen are fulfilling their primary charge of advocacy on behalf of LTC residents. Huber notes that, although the states chosen for her analyses had more sophisticated data management systems, they were not considered different in size or other characteristics from other states.

Overall, complaints were filed with ombudsmen by family and friends, residents, facility and provider staff, representatives of other agencies and programs, and others such as guardians and legal representatives. Also, ombudsmen themselves frequently notice situations that demand further investigation. According to both Huber’s database and nationwide data (AoA, 1994c), complaints filed address problems primarily related to residents’ rights, resident care, quality of life, legal guardianships, and administrative issues. Neither Huber nor other researchers have found any conclusive evidence to support linking effectiveness of the ombudsmen program with the sources that initially file complaints nor with the types of complaints that are reported, investigated, or resolved.

Through analysis of information provided by state ombudsmen in their annual reports and responses to the canvass, Chaitovitz concludes that ombudsmen in local programs serving residents of nursing facilities function as expected: they advocate for residents in nursing facilities, report and resolve complaints, mediate disputes, and educate residents and staff of nursing facilities.

In general, little research has investigated the extent to which ombudsmen are involved in B&C facilities. The studies that do exist raise a number of issues and concerns regarding complaint resolution in these facilities. According to Phillips and colleagues (1994), two-thirds of ombudsmen interviewed in his study did not believe they were responsible for regular visits to B&C facilities. This indicates a lack of awareness of the obligation of the program. The program’s lack of presence in B&C facilities would likely constrain residents’ ability to register complaints with the ombudsman. Also, many B&C homes are small, and the environment (both physically and socially) is not conducive to protecting the privacy of the complaining resident (see Reschovsky and Ruchlin, 1993).

Ombudsmen in many states use data about complaints to monitor activities of the local ombudsmen and individual (or chains of) facilities, and to identify possible areas for training, technical assistance, or on which to focus strategies that advocate for systemic changes (Chaitovitz, 1994b; Huber, 1994; Kautz, 1994).

Huber notes that, although numbers and types of complaints and how they are handled in part demonstrate the effectiveness of the ombudsman program, complaint data show nothing about the effectiveness of ombudsmen in preventing problems in their communities and LTC facilities. At one IOM committee

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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hearing, ombudsmen cautioned about relying too heavily on complaint-specific data to assess effectiveness. They stressed that one of the major effects of their work is to prevent complaints from occurring through education and through their attempts to resolve problems before they escalate into formal complaints. Chaitovitz (1994b) also notes that state ombudsmen expressed concern about what complaint-specific data does not show. Such data do not indicate how many residents are unaware of the ombudsman program but may have need of it.

Research on complaints highlights the level of activity of the ombudsman program in responding to consumer-initiated requests but lacks specificity with regard to complaint resolution and the linkage between complaint resolution and quality of care at the individual, facility, and system levels.

Providers’ and State Agency Directors’ Perspectives

Researchers obtained information from several sources on providers’ attitudes and perceptions of the purpose, value, and effectiveness of the ombudsman programs. In a paper commissioned for the committee, Lusky and colleagues (1994) report on a survey of administrators, directors of nursing, and social workers in randomly selected nursing facilities in substate regions with the “most active” regional ombudsman programs (as designated by the state ombudsman). Additionally, the investigators’ findings reflect input from focus group discussions with providers of both not-for-profit and for-profit nursing facilities, as well as state and national leaders in the industry. The committee used the work done by Phillips and colleagues (1994) to garner the views of staff of B&C homes. To obtain first-hand information, the committee met several times with leaders and staff of nursing facility and B&C providers, in conjunction with site visits and special panel discussions.

Generally, providers are uncertain about many of the goals and objectives of the ombudsman program and state that the goals, objectives, organization and methods of the program have never been clearly spelled out. Providers observed that operation of the program varied by individual ombudsman, facility, region, and state. These observations demonstrate the difficulties involved in evaluating the program’s overall effectiveness. Insofar as they had views, nursing facility providers’ perceptions about the program seemed to cluster around the following themes:

  • The ombudsman program is useful, especially in helping resolve family issues affecting residents and in articulating residents’ rights and facility responsibilities, although the extreme variability among programs made generalizations difficult. Since they are separate from facility staff, ombudsmen are typically perceived by residents and family to be more neutral and objective.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Their separateness also is an asset that is useful to facilities in dealing with resident problems. Among those who perceive the program as useful is a subgroup that harbors doubts about the cost-effectiveness of the program.

  • Measures of performance and effectiveness that rely on numbers of complaints or percentage of complaints resolved are of questionable validity. Nursing facility providers believe that the ombudsman reporting system creates incentives to show high numbers of complaints.

  • Most of the problems with perceived poor-quality ombudsman programs centered on issues of selection, training, and supervision of ombudsmen, and in particular of volunteers. Staffing-related issues were seen as the most critical prerequisites to a high-quality ombudsman program. Providers felt that effective programs depended on such other factors as leadership, personality, and resources.

  • The concept of advocacy as operationalized by some ombudsmen creates ambivalence within the provider community. Advocacy causes a blurring of roles among the ombudsman, regulators, protective services, and legal services. Nursing facility staff feel some ombudsman programs have anti-facility biases and inappropriate adversarial attitudes.

  • The information from B&C staff about their perceptions on the usefulness and effectiveness of the ombudsman program is more sparse and less informative. Drawing on information gathered from one of the Research Triangle Institute studies, Phillips and colleagues (1994) note that, although a majority of B&C staff participating in the study indicate that they are aware of the ombudsman program, they do not refer residents or their families to the program.

As explained in Chapter 2, the Office of the State LTC Ombudsman program is often located within the SUA. The committee sought information from SUA directors about their perceptions on pertinent aspects of the program. The 41 respondents gave the following information (percentages reflect the proportion of respondents whose answers to open-ended questions were consistent with the statement):

  • The state ombudsman programs provide information about trends and issues that affect the well-being of LTC residents (80 percent).

  • The state ombudsman programs are not at full implementation (51 percent) because of lack of sufficient resources, or are at the best possible level of implementation given the present level of resources (29 percent).

  • Legislative and regulatory powers provide adequate authority to the program (66 percent).

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Adequacy and Management of Volunteers

Volunteers often constitute an important resource for the ombudsman programs. The committee did not take a position on whether all programs should use volunteers but elected to emphasize that volunteers, if used, are a resource that deserves a high level of support. If adequately supported, volunteers can make significant contributions to the ombudsman program’s performance (Litwin and Monk, 1987; Monk and Kaye, 1982b; Schiman and Lordeman, 1989b; OIG, 1991a,b,c; Huber et al., 1993; Nelson, 1993; AARP, 1994a). Although no conclusive findings have shown a causal relationship between volunteers and outcome measures of the quality of life of residents, recent findings by Nelson and colleagues (in progress) indicate that the presence of Oregon volunteer ombudsmen is related to increased reporting and handling of abuse complaints, increased letters of reprimand, and higher numbers of identified survey deficiencies. These findings are consistent with patterns of program activity observed in the OIG (1991a,b,c) study suggesting that volunteers are an important contributing factor to high complaint resolution rates. Specifically, the OIG found that the worst record for complaint resolution was in a state that had no volunteer program. This state closed only 25 percent of the complaints within a 12-month period, compared with an average of 75 percent for the majority of the model programs (as defined in the OIG study) and 56 percent of the less successful programs.

Nelson (1993) documents the importance of sound methods of screening, recruiting, training, and supervising volunteers. His research suggests that the more volunteers become committed and dedicated to the organization, the more closely their performance will be in concert with and enhance the effectiveness of the ombudsman program. In keeping with other research, Nelson found that volunteers experience job stress, strain, and lack a sense of accomplishment in situations where there is a lack of job clarity. His work on role conflict is particularly relevant to the use of volunteers in the ombudsman programs. He concludes that ombudsman program managers must provide clear role definitions for volunteers and provide adequate training and support to help eliminate incorrect or vague role expectations. Nelson postulates that providers may also be unclear about their expectations about the role of volunteer ombudsmen. This lack of understanding, he speculates, may add to the sense of ambiguity volunteer ombudsmen may experience. Similar to a recommendation made by Litwin and Monk more than a decade ago (1984), Nelson supports building awareness among providers through mechanisms such as training and publicity. These mechanisms may help them develop more realistic expectations about volunteers in the ombudsman program.

At the time the committee was writing this report the AoA had not released the training standards called for in the 1992 amendments to the OAA. The committee did not develop a position on training curriculum nor the minimum

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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number of hours appropriate for either initial training or inservice training. Nevertheless, the committee concurs with the views expressed by many who are actively involved with the program—including providers, ombudsmen, and SUA directors—with regard to the importance of well-trained volunteers (and staff).

No definitive guidelines specify what constitutes an adequate level of paid staffing or a mixture of paid and volunteer staffing for an ombudsman program. (In Chapter 6 the committee discusses paid staffing levels in the context of performance and adequacy of resources.) Paid staff to volunteer ratios differ widely across the ombudsman programs (see Table 2.3 in Chapter 2). A task force working under the auspices of Legal Counsel for the Elderly (AARP, 1994a) noted that some of the most successful ombudsman volunteer programs employ one person to serve as full-time coordinator or director of volunteers if the program has a volunteer staff of 20 or more. The task force emphasizes the importance of the coordinator not taking on other responsibilities. Well-trained and supervised volunteers in most circumstances can deliver the same ombudsmen services as paid staff, provided volunteers have equal authority and receive similar support from those with whom the ombudsman works on behalf of residents.

Barriers to Effectiveness

General Problems and Impediments

Many of the barriers to ombudsman program effectiveness at both state and local levels are apparent from the discussion thus far. Briefly, they include: insufficient funding at both state and local levels (the barrier most frequently named by state ombudsmen); lack of professional staff and inability to use volunteers; lack of clear lines of authority and accountability for ombudsmen at all levels; restrictions on program autonomy or subordination to other agencies in LTC; and legislative or regulatory restrictions on ombudsman activities (which sometimes put ombudsmen out of compliance with federal legislation). Further details on some of these points are given below.

Sometimes, the ombudsman programs do not function as intended because of state variations in enabling legislation. Selected states among those who are forbidden to use volunteers cited this as a barrier to effectiveness. Some ombudsmen commenting on this issue to the committee attributed the prohibition on using volunteers to the lobbying efforts of some individuals in the nursing facility industry. They allege that these individuals would prefer less

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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professional advocates and more “friendly visitor/mediator” volunteers.4 Others report opposition by area agencies on aging (AAAs), stating that AAAs believe that potential volunteers and AAA program constituents may be discriminated against by ombudsmen because they lack skills believed to be desirable for the ombudsman program (Chaitovitz, 1994b).

The lack of a uniform database and modern methods of communication (such as computer networks or teleconferencing) keep the ombudsman programs in relative ignorance of each other and inhibit them from sharing common problems and, more importantly, solutions that have worked in various environments and settings.5 Help in developing information systems was requested by 40 percent of state ombudsman programs (Chaitovitz, 1994b).

Adequate evaluation of the ombudsman program will depend significantly on the collection of uniform data on program expenditures, staffing, activities, and the outcomes of these activities (such as changes in practices within LTC facilities that promote individual autonomy and development of laws or regulations in LTC). Measures of program outcomes (such as those in Table 5.1 ) should eventually be incorporated into routine, standardized data collection available for public use, most of all by ombudsmen themselves for their own use in management information systems and as indicators of program performance.

Details about certain key impediments to effective functioning of the ombudsman program emerged from the canvass of state ombudsmen (Chaitovitz, 1994b). State ombudsmen judged that the greatest barrier to overall effectiveness of the program was insufficient funding, which in turn meant insufficient professional staff (a point reiterated in Chapter 6). Moreover, inadequate finances also meant that states could not effectively recruit or train volunteers, publish educational materials, train volunteers on the special needs of important subpopulations such as the mentally ill elderly, have enough seed money to raise funds from the private sector, support full-time, well-qualified local professional staff, or reimburse volunteers for travel expenses and the like.

When state ombudsmen were asked about barriers to effective advocacy, 22 percent of them (n=50) indicated problems with a strong industry lobby, 18

4  

As stated earlier, the concept of advocacy as operationalized by some ombudsmen creates ambivalence among some, but not all, providers. According to Lusky and colleagues (1994), providers are supportive of efforts to recruit and train mediation-oriented ombudsmen, but many in the provider community continue to bristle at the thought of granting ombudsmen greater authority in the realm of advocacy at the system level.

5  

Several state ombudsmen noted that their programs have benefited from the technical assistance provided through the AoA-funded national resource center. The resource center, however, has not been funded to a level that would support serving the hundreds of local ombudsman programs.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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percent indicated problems with either the SUA or AAA, and 10 percent indicated problems with regulatory agencies. Six states also noted that they lacked the time to direct toward systemic advocacy efforts (Chaitovitz, 1994b).6

Almost 20 percent of state ombudsmen canvassed felt that the aging network was apathetic to the plight of the institutionalized aged and the ombudsmen did not see this group as among their constituents. Furthermore, from the perspective of state ombudsmen, some AAAs appear to be under local political pressure to discourage advocacy.

In any case, the state ombudsman has no direct authority over AAAs. If the AAA accepts the local ombudsman program, and then adds local funds, the AAA is likely to resent program direction initiating from the state ombudsman. Some AAAs may believe the SUA or the state ombudsman program should be directly responsible for the local ombudsman program. They feel that they have been forced to accept responsibility for a program that they did not choose and do not see as their legitimate responsibility. Ombudsmen also regard their relative lack of power in relation to state agencies as a major barrier to program effectiveness.

Yet other issues arise with respect to B&C homes. As reported by Phillips and colleagues (1994), ombudsmen cited a wide array of concerns, most of which parallel those related to the traditional constituencies of ombudsmen. Again, ombudsmen stressed the need for increased funding and, related to this, the need for more staff and volunteers. Deficiencies in the regulatory process, particularly in terms of enforcement, were also cited, as was the need for a more effective relationship between the ombudsman program and the state agency with enforcement authority. In this same vein, the need for more cooperation from or more effective networking with other agencies was also noted. More broadly, finding creative ways to foster greater public awareness of the ombudsman program was seen as a significant challenge. An impediment to effective performance in the B&C arena was the lack of clear guidance on how to advocate for special populations (e.g., persons with developmental disabilities, dementia clients).

A variety of other problems vitiate the effectiveness of the ombudsman program, at least in some states. For example, some respondents call attention to political and social climates hostile to dependent persons of any age or type. In addition, the difficulties of traveling to LTC facilities located in high-crime areas or winter travel in remote rural areas loom as a major hindrance to ombudsmen. Others complained of union interference with ombudsman efforts targeted on nursing facility staff practices.

These responses suggest another major area in which system change must take place if the effectiveness of the state ombudsman program is to increase. Apparently, in many locales relationships between the programs and the aging

6  

Many respondents cited multiple barriers.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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network have evolved without an overall sense of purpose or direction. Consequently, some entities that might have become involved with the ombudsman program in worthwhile ways have not. These gaps should be addressed. For example, closer links between the ombudsman program might be developed with the Health Care Financing Administration, which administers both the Medicaid and Medicare programs (Holstein, 1994). In short, the role of the aging network in LTC is changing and expanding. In order to enhance the capabilities of the ombudsman program and to enable it to meet its growing mandate, organizational and system structures must be rethought. Strategic planning for the next 10 to 20 years is also sorely needed.

Barriers to Effectiveness in the Local Ombudsman Program

A canvass of local ombudsmen evoked committee concern about local program effectiveness as well. The canvass identified four main categories of problems, which generally paralleled those reported at the state level.

The first is funding. At the local level, this translates into lack of control over financial and other resources. Without such control, local ombudsmen cannot control budgets, raise additional funds, or provide continuing education for staff, volunteers, or the community in general. The ombudsmen also cited their inability to obtain needed legal services, both for residents and for themselves, and felt this lack was a troublesome problem related at least in part to funding deficiencies.

The second category of problems, also related to funding, centers on staffing. Programs lack staff and volunteers with appropriate skills. In at least one area, the lack of local ombudsmen speaking languages other than English was considered a serious hindrance to effective performance. Programs also sorely need staff with skills in nursing and LTC or with knowledge of health issues or the law. In addition, facilities are insufficiently covered owing to lack of staff or volunteers. This deficiency translates into inadequate response times to complaints and a general inability to conduct thorough investigations. Turnover rates among volunteers owing to age and to role misunderstandings (which may itself be a consequence of inadequate training) was yet another staffing issue of concern to local ombudsman programs. Local ombudsmen noted that the turnover rate is also high among paid staff in local programs, and they attributed this to low pay scales, role misunderstandings, and frustrations over the lack of authority to make changes.

Systemic advocacy work constitutes a third area of concern. Because local ombudsmen often lack the ability and time to analyze series of separate incidents, they may not identify significant patterns as well as difficulties in working with local health departments. All of this impedes their ability to improve quality of care in facilities.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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A fourth set of problems relates to interagency relationships. During at least one site visit, as well as in the canvass of local ombudsmen, it was evident that these programs had uncertain and sometimes conflicting relationships with other local programs dealing with aspects of LTC, such as abuse protection programs, offices of conservatorship, and local offices of licensing and certification. Local programs had to work out these arrangements on an individual basis. No structural support or legislation defined the parties with whom they were to have relationships, and no sanctions were available if these parties refused to cooperate with the ombudsman program. Related to this was the question of roles and relationships with AAAs. Whether local ombudsmen were (or could be, or should be) simply AAA employees was unclear, as they then could be asked to take on other duties seen as having higher priority than core ombudsman responsibilities.

The ombudsman program as a whole seems to experience more systemic problems on the local level than it does on the state level. To a large extent, these problems appear to be attributed to the ways in which state programs contract out for these local ombudsman programs, if they have them. Lines of accountability, from state ombudsman programs to local programs, and from local ombudsman programs back to state programs, are unclear if contracting occurs through third parties such as AAAs that in turn subcontract the ombudsman programs to entities further removed from the front line of accountability. When contracting is done through AAAs, the interest of particular AAAs may determine priorities for local ombudsman programs.

Committee Reflections on Data

The committee devoted considerable time and debate to the status of existing data systems and data requirements for the ombudsman program. The committee was frustrated over the uneven and scanty quantitative (not to say basic program) information available during the study period. The site visits and various canvasses of appropriate officials (ombudsman at the state and local levels, directors of SUAs, and so forth) provided much useful qualitative, and some quantitative, information, but these sources of data did not, and were not expected to, substitute for more systematic, longitudinal, and reliable program data. In short, hard data were conspicuous in being essentially absent. Similar conclusions were reported by GAO (1992b).

The committee supports activities now under way by the AoA to implement a revised reporting system for complaints and LTC issues—the National Ombudsman Reporting System. Although the general thrust of this endeavor is laudable, the committee does have some concerns about the nature and large number of data elements to be collected and mechanisms for ensuring that reliable (reproducible) information would be reported across the states and

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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localities. However, it believes that the present effort is an improvement over the earlier reporting system and is one that could be amended as experience accumulates.

On a broader note, the committee notes that the importance of uniform, reliable, and valid documentation of the work and effects of the program is consistent with the Government Performance and Results Act of 1993 (GPRA, Public Law 103–62), which reflects the current congressional view that federal funding should be based on program outcomes (see Chapter 3 for a discussion of the relevance of GPRA to the ombudsman program).

Huber (1994) notes the core challenge inherent in the new law: to more carefully document the work of ombudsman. “Many deliverers of social services did not learn their jobs with the knowledge that how carefully they document their work could well determine future funding for their services to be kept available to clients. Most ombudsmen cringe from paperwork, but with the advent of [GPRA], careful documentation is now critical” (p. 64). She correctly observes that the strongest motivator for ombudsmen to collect better data is for them to see their own data in quick and useful form, and she argues that AoA should facilitate the development of a mechanism to provide a central processing and reporting service to state and local ombudsmen. The committee concurs with the argument that “AoA should encourage and financially support the growth of rigor and sophistication in database development.” Huber further recommends, for example, that “future data gathering for the ombudsmen program should include survey data from state agencies which inspect facilities toward licensure; and resulting citations (or lack thereof) should be included in ombudsmen databases for correlation with complaints by facility” (Huber, 1994, p. 64 ff).

CONCLUSIONS AND RECOMMENDATIONS

Continuance of the Ombudsman Program

In this chapter the committee has attempted to assess the effectiveness of the state LTC ombudsman program from several perspectives. The underlying impediment to the committee has been the lack of reliable and valid information on this topic that could be fit into any defensible summative evaluation format. For that reason, the committee opted for a formative evaluation effort—one that would highlight program issues, strengths, and weaknesses and one that would point to more specific questions deserving in-depth attention in the coming years. The remainder of this chapter summarizes the conclusions the committee regarded as legitimate to draw from the information at its disposal and then presents the recommendations it believes are justified by those conclusions.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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First, on the basis of all the information it reviewed, collected, and analyzed, the committee concludes that the ombudsman program serves a vital public purpose. Every year the LTC ombudsman program helps many thousands of individual LTC facility residents, particularly those in nursing facilities, with a wide range of problems and concerns. At the direct request of residents, their families, LTC facility staff, and others, individual resident advocacy services of staff and volunteer ombudsmen uniquely contribute to the well-being of LTC residents, complementing but not duplicating the contributions of regulatory agencies, families, community-based entities, and providers. Examples of effective services range from solving such everyday problems as the bath schedule of individual residents to resolving serious issues such as evictions and involuntary transfers.

The committee thus takes a strong supportive stance with respect to the ombudsman program. To underscore this commitment to the mission of the program:

5.1. The committee recommends that Congress continue the long-term care ombudsman program as set forth in the Older Americans Act.

Stating such a recommendation may seem superfluous from a group empaneled to examine a program that, on the face of it, serves a worthy cause and a needy population. This recommendation renders explicit an assumption at the basis of all recommendations made up to this point. However, the committee took seriously the question of whether the program merited continuation in its present form (or at all). Having concluded that it does, the committee intended, through the above recommendation, to make clear that the aims of those who crafted the original program and its subsequent modifications remain consequential today.

The LTC ombudsman program can justly claim to have improved the system of LTC services. Through systemic advocacy work and educational efforts, the state programs, individually and collaboratively, have brought to the attention of state and federal policymakers, regulatory agencies, and provider organizations a host of conditions that can and should be changed to improve the health, safety, rights, and welfare of LTC residents. Examples of changes advanced or promoted by ombudsman programs (often in conjunction with other organizations) include: enactment of the federal Nursing Home Reform Law of 1987; increased personal needs allowances; protections from involuntary discharge and room transfers; reduced use of physical restraints; improved building and safety standards; increased state funding for inspection and surveying of LTC facilities; reduced use of psychotropic medications; better licensing oversight of health care professionals; increased use of advance directives; increased LTC staff competencies and sensitivities; and empowerment of residents through stronger resident and family governance structures.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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In the B&C area, the ombudsman program has been partially implemented at best. Hence it is premature to evaluate its effectiveness as a national program in this area. The committee found many ombudsmen to be substantially inactive and unresponsive concerning their B&C mandate. However, the committee also observed examples in which ombudsmen have been effective in resolving B&C complaints where there is a regulatory background within which they can work for the rights of the individual. At the systemic level, the regulatory structure is just now emerging for B&C facilities. Ombudsmen perceive themselves to be constrained by the lack of regulatory structure. In some cases, they contribute to the development of concepts that should be incorporated into the regulatory structure for this rapidly evolving industry.

Exemplary Practices and Performance

The committee believes that the individual and system successes attributed to the ombudsman program occur despite considerable barriers in most, if not all, states. Inadequate funding, resulting staff shortages, low salary levels for paid staff, structural conflicts of interest that limit the ability to act, and uneven implementation within and across states create obstacles to effective performance. In many parts of the nation, even the program’s primary service responsibility—to resolve the problems and concerns of individual LTC residents—simply is not met. The committee observed such barriers as absence of local ombudsman programs from some areas of states, little or no individual resident advocacy services for B&C residents, and exclusive reliance on one centralized toll-free telephone line for an entire state with little or no opportunity for face-to-face advocacy services by ombudsmen on behalf of residents. In many states, the program attempts to operate in a structural environment that expressly prohibits or does not foster its ability to carry out all federally mandated functions. For example, in some states, state and local ombudsmen are prohibited from talking with any state or federal legislators about issues of concern to residents. Also, some ombudsmen attempt to carry out conflicting roles, such as ombudsman and APS official, simultaneously.

As a consequence of what it perceived to be the significant drawbacks of this variation in basic program implementation and practice, the committee has developed a detailed scheme of “Elements of Infrastructure and Functions,” as detailed in Tables 5.2 through 5.9. These elements are expressed in terms of exemplary, essential, and unacceptable practices. They incorporate prerequisites for effective ombudsman program performance. Committee members underscored their belief in the value of building upon these “ideal types” of practices as a basis for objectively measuring compliance with the legislative mandate. In addition, the exemplary model practices offer a standard and

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

challenge for ombudsmen programs to reach in terms of higher levels of effectiveness and service. Thus:

5.2. The committee recommends that the Administration on Aging build upon the committee’s proposed set of exemplary, essential, and unacceptable practices to develop and implement an objective method to assess compliance of state long-term care ombudsman programs.

The proposed set of ideal practices might initially be used in numerous ways to informally test their applicability and usefulness. For example, AoA may find them helpful in the upcoming pilot ombudsman performance-reporting project to be conducted in conjunction with GPRA. State ombudsmen might host workshops for LTC facility providers, licensing and certification staff, SUAs, and others to review the practices and perhaps adopt elements of the standards as short- and long-term milestones toward which they will jointly strive to move the ombudsman program. Similarly, the state and local ombudsman, SUAs, AAAs, and other designated representative entities might formulate mutual plans of action that focus on strengthening one or more of the infrastructure elements.

The national ombudsman resource center may find the set of ideal practices helpful as training tools. The resource center may also serve as a national clearinghouse for tracking activities that focus on the proposed set of standards. Feedback could then be provided to AoA as it moves forward to adopt a more formal compliance assessment instrument and methodology.

Monitoring and Evaluating Effectiveness: Data and Information Systems

Because the ombudsman program is still developing and evolving, and because data on program performance are not available, it is not possible to evaluate the program’s effectiveness. Agreement has been lacking about the definition of goals; implementation has been extremely varied, stemming in part from broad and uneven interpretations of the OAA mandate; and no formal evaluation component was ever built into the program. Only recently has AoA adopted a standardized data-reporting system of any complexity.

Of all these issues, the committee focused on information systems as an area that AoA could and should remedy. Accordingly, it developed a set of recommendations in this area.

5.3. Building on work already begun by the Administration on Aging and the National Association of State Long-Term Care Ombudsman Programs, the committee recommends that the Secretary and Assistant Secretary for Aging, Department of Health and Human Services, establish

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

and implement an information system for the ombudsman program that provides an empirical basis for:

  • evaluating and improving complaint resolution efforts by identifying the extent to which ombudsmen have been effective in resolving complaints and issues to residents’ satisfaction;

  • identifying more precisely the kinds of problems (resolved or not) that affect the lives of residents of nursing and residential care homes in order to provide a basis for systemic advocacy and change;

  • documenting the key efforts made toward systemic advocacy and the results of those efforts to address priority long-term care issues; and

  • documenting and analyzing the full range of activities of the long-term care ombudsman programs.

To follow up this overall recommendation about information systems for the ombudsman program—reflecting its concern about the paucity of comprehensive and accurate data to assess program activities and performance—the committee concluded that additional, more specific, or more technical points should be made with respect to data and information systems. The two recommendations pertaining to these points are as follows:

5.4. The committee recommends that the Assistant Secretary for Aging continue the efforts of the Administration on Aging to develop, refine, and implement a uniform data collection and reporting system. The committee recommends, at a minimum, that the data system should:

  • be based on a manageable number of uniform and reliable data items—each of which has precisely specified, field-tested definitions;

  • be derived from annual statistical reports submitted by state long-term care ombudsman offices that provide information in terms of the data items in the previous point;

  • include a clear indication of status of complaint resolution from a consumer perspective;

  • be used to provide feedback to state and local ombudsman programs;

  • be available for public use to foster research and inform decision making;

  • incorporate methods and procedures for continuous revision and improvement; and

  • be reviewed and updated no less than once every three years.

5.5 The committee recommends that the Assistant Secretary for Aging periodically conduct audits of the data collection and reporting

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

systems of state ombudsman programs to ensure that all states adhere to the national standards of the uniform data collection and reporting system.

The committee underscored the importance of well-defined, accurately reported uniform data collection in which each item has precisely the same meaning for all state programs. Committee discussion emphasized the necessity of assuring that the burden of reporting is minimized and realistic, given the fact that staff resources are limited and that volunteers are crucial in data collection efforts. Time spent recording data is time not available for direct service. Thus, all items intended for a formal data collection instrument should be carefully examined and included only if they have demonstrated utility for AoA or state or local ombudsman programs (or, ideally, both). Preference should be given to items that are useful in documenting the nature and outcomes of the full range of ombudsman services. This requires that items be reliable and valid for purposes of computing measures of program outcomes and effectiveness such as consumer awareness, consumer problem resolution, and LTC system change. The data collection system requires periodic review and revision to assure its continuing relevance, utility, and validity. Further, the committee emphasized the value of auditing data that are collected, on a sample basis, to ensure their accuracy and adherence to reporting standards.

Committee members expressed particular interest in the value of all state ombudsman’s offices commenting consistently on four specific elements of information, described in Recommendation 5.6 below.

The committee expressed concern that the limited resources of the ombudsman program may impede or prevent these necessary reporting systems from being fully or effectively operationalized across the states. It concluded that both additional resources and a commitment by AoA to training and motivating ombudsmen in how the data systems may be used to improve their own programs would be needed. Considerations of the adequacy of resources (see Chapter 6) must include finding the financial resources to support the paid and volunteer staff needed to fulfill the monitoring and reporting requirements suggested here.

5.6. The committee recommends that the Secretary and Assistant Secretary for Aging, Department of Health and Human Services, require that each Office of the State Long-Term Care Ombudsman include in its annual report, in addition to currently required elements, information on and comments about:

  • the level of awareness of residents, their agents, and other parties regarding the ombudsman program, and the availability of ombudsmen to individual residents;

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×
  • the extent to which the complaints and concerns of residents have been satisfactorily resolved;

  • the extent to which ombudsmen have provided input into activities designed to improve the overall system of care and services for long-term care residents; and

  • the extent to which ombudsmen have improved the overall system of care and services for long-term care residents.

The committee is interested especially in encouraging the ombudsman programs to enhance the content of their annual reports with more information that specifically focuses on outcome measures. Much resident-specific outcome information is protected by confidentiality practices, and correctly so. However, the annual reporting format provides an excellent vehicle through which programs can begin to publicly track process activities (such as number of visits made, number of resident council meetings attended) in conjunction with outcomes such as results of surveys of residents and their family members regarding awareness of and satisfaction with the ombudsman services.

The committee reviewed selected annual reports that provided more outcomes information than required by this recommendation. In order for reports of this nature to be produced, programs must be adequately staffed. However, with current funding levels, many ombudsmen have little time to direct toward systemic advocacy and even less time to document such efforts. Nevertheless, the committee argues that the Office of the State LTC Ombudsman should account routinely to the public and describe the efforts that have been taken by the office to improve the LTC system and, to the extent that the information is known, the results of those efforts.

Research Imperatives

As noted earlier in this chapter, almost no evidence exists that links in a causal manner the activities of the ombudsman program (such as participating in nursing facility surveys or developing an annual report) with such outcomes as changes in LTC facility practices that show more respect for residents’ rights or changes in state or federal laws that provide legislative backing for residents’ rights. Just as research is being conducted to assess linkages between process, structure, and outcomes in various aspects of our health care system, so too the need exists for such research relative to the LTC ombudsman program. To this purpose, the committee offers the following recommendation.

5.7. The committee recommends that the Administration on Aging, the Health Care Financing Administration, the Agency for Health Care Policy and Research, other government agencies, and foundations support

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×
  • the extent to which the complaints and concerns of residents have been satisfactorily resolved;

  • the extent to which ombudsmen have provided input into activities designed to improve the overall system of care and services for long-term care residents; and

  • the extent to which ombudsmen have improved the overall system of care and services for long-term care residents.

The committee is interested especially in encouraging the ombudsman programs to enhance the content of their annual reports with more information that specifically focuses on outcome measures. Much resident-specific outcome information is protected by confidentiality practices, and correctly so. However, the annual reporting format provides an excellent vehicle through which programs can begin to publicly track process activities (such as number of visits made, number of resident council meetings attended) in conjunction with outcomes such as results of surveys of residents and their family members regarding awareness of and satisfaction with the ombudsman services.

The committee reviewed selected annual reports that provided more outcomes information than required by this recommendation. In order for reports of this nature to be produced, programs must be adequately staffed. However, with current funding levels, many ombudsmen have little time to direct toward systemic advocacy and even less time to document such efforts. Nevertheless, the committee argues that the Office of the State LTC Ombudsman should account routinely to the public and describe the efforts that have been taken by the office to improve the LTC system and, to the extent that the information is known, the results of those efforts.

Research Imperatives

As noted earlier in this chapter, almost no evidence exists that links in a causal manner the activities of the ombudsman program (such as participating in nursing facility surveys or developing an annual report) with such outcomes as changes in LTC facility practices that show more respect for residents’ rights or changes in state or federal laws that provide legislative backing for residents’ rights. Just as research is being conducted to assess linkages between process, structure, and outcomes in various aspects of our health care system, so too the need exists for such research relative to the LTC ombudsman program. To this purpose, the committee offers the following recommendation.

5.7. The committee recommends that the Administration on Aging, the Health Care Financing Administration, the Agency for Health Care Policy and Research, other government agencies, and foundations support

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

5.8. The committee recommends that the Assistant Secretary for Aging establish a standard for ensuring the adequate management of volunteers who serve as designated ombudsmen. The committee suggests that the ratio of staff to volunteers be in the range of 1 paid full-time equivalent manager for every 20 to 40 volunteers.

The committee based this ratio on the literature, the experience of its members, and those ombudsman programs with whom the committee consulted. The actual number of individual volunteers relative to paid staff, independent of the number of hours donated per week by each volunteer, is relevant to setting such a standard. The intensity of such staff functions as recruitment, orientation, training, and supervision are largely dependent on the quantity and turnover rate of volunteers.

Supervising a volunteer ombudsman program is no small task. At a minimum, it requires an ongoing recruitment or publicity campaign using all means of free media available to find additional or replacement volunteers. The supervisor frequently conducts initial training of all new recruits after screening for conflicts of interests. Supervision continues with the provision of ongoing guidance and assistance to all volunteers by conversing by telephone at least weekly, monitoring written reports filed by volunteers, and answering questions on an as-needed basis. Most volunteer programs also produce regular newsletters or issue news alert bulletins in addition to conducting regular in-service training sessions.

In some programs, volunteer coordinators have other responsibilities as well. A coordinator may be responsible for resolving selected complaints or working on cases that are not assigned to a volunteer or another staff member (e.g., a facility in which a complaint arose has no volunteer coverage or the issue is complex and not one that a volunteer has been trained to handle). Coordinators may also be responsible for analyzing complaint data for systemic advocacy work and conducting educational training sessions for LTC facility staff, residents, and family councils.

Thus, in setting the standard recommended here, the span of control and management of individuals was emphasized rather than the quantity or type of effort provided per volunteer (i.e., total number of hours volunteered per week or whether the volunteer serves as a friendly visitor or as a designated ombudsman). All volunteers working under the auspices of the ombudsman program can make their most valuable contributions if they are working with an efficiently managed program. (See Chapter 2—Human Resources section—for details on volunteer resources in the ombudsman programs.) The committee noted that it suggests a minimum standard, particularly at the 1:40 level. It strongly encourages state LTC ombudsman programs to maintain paid staff-to-volunteer ratios at levels that are far more robust than the 1:40 level.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

SUMMARY

The committee’s efforts to assess the effectiveness of the state LTC ombudsman program from several perspectives were hampered by the lack of reliable and valid information. Its efforts, therefore, highlighted program issues, strengths, and weaknesses. On the basis of all the information it reviewed, collected, and analyzed, the committee concludes that the ombudsman program serves a vital public purpose. In its assessment, the committee identified considerable barriers to effective performance that the ombudsman programs encounter. Significant among these are inadequate funding, resulting staff shortages, low salary levels for paid staff, structural conflicts of interest that limit the ability to act, and uneven implementation within and across states.

The committee developed a detailed set of ideal practice standards to guide AoA and the ombudsman programs toward more effective basic program implementation and practice. The committee made several recommendations to enhance a nationwide, standardized data collection and reporting system. Information about the outcomes of the ombudsman program is essential and the committee recommended that Offices of the State LTC Ombudsmen include outcomes data in their annual reports. Research is needed to further the understanding of the links between the activities of the ombudsman program and such outcomes as changes in LTC facility practices that show more respect for residents’ rights. Adequate human resources are an essential prerequisite to effectiveness, and well-run programs provide quality management of volunteer resources.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.2 Structure of the Office of the State LTC Ombudsman and Elements of the Host Agency(s) for the State and Local Entities

Exemplary Practices

Essential Practices

Unacceptable Practices

The committee recognizes that its Recommendation 4.1 calls for an essential practice that will have a major impact on the majority of state ombudsman programs. Presently, in a majority of states, the state ombudsman is not housed in a totally independent state agency or contracted out to an independent nonprofit agency. The committee’s recommended exemplary practice for structure therefore calls for a thoughtful extended transition to new organizational “homes” for parts or all of the ombudsman program. An exemplary transition will examine the current structure of the Office, determine the components housed in regulatory or provider settings, determine the alternative settings for housing those program elements, and develop a plan for transition that maximizes the existing strengths of the program and builds toward the other essential and exemplary practices.

The Office of the State LTC Ombudsman is placed in a totally independent state agency, solely or primarily focused on LTC issues or it is contracted out to an independent nonprofit agency. This conclusion is based on the committee’s overall study and the current effectiveness of programs. Consistent with Recomendation 4.1, “totally independent” means that the agency is not responsible for regulating, providing, managing, determining eligibility for, or paying for LTC services or protective services.

State or local ombudsmen operate in an agency with many prohibited ties to regulatory or provider agencies.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

 

The state ombudsman is the head of the Office of the State LTC Ombudsman program and controls the administrative, advocacy, and budget decisions of the Office. The state ombudsman is independent in all actions but reports and consults with the head of the SUA or their designee to ensure identification and resolution of agency-wide issues, programmatic and fiscal integrity, and coordination of efforts.

The state ombudsman’s independent authority and discretion to take significant administrative, advocacy, or other actions related to the program is materially limited by the agency’s hierarchy, policies, or procedures.

The state ombudsman has no control over the budget of the Office; decisions are made by others. The state ombudsman is refused authority to speak to elected officials, the media, or other parties on a specific issue or in general.

State and local ombudsmen are housed in an agency dedicated to representing the interests of LTC facility residents through an effective ombudsman program.

Local programs operate totally independent of or hostile to the state ombudsman or vice versa; the state ombudsman views his or her role as “regulator” of local programs and has little vision of the Office as a unified entity.

Resident and ombudsman interests are not secondary to other agency programs and client groups.

Local ombudsmen have no clear authority to take any administrative, advocacy, or other action related to the program without clearance by someone other than the state ombudsman.

Ombudsman financial and human resources are expended solely on ombudsman program needs.

State or local ombudsmen funds, time, or other resources are being used to subsidize or provide non-ombudsman functions.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.3 Qualifications of Representatives of the Office

Exemplary Practices

Essential Practices

Unacceptable Practices

Representatives have backgrounds in advocacy, problem solving, consumer education, LTC, or community organizing. All representatives with supervisory responsibilities have experience with management and program administration.

Representatives possess the skills to perform the duties and responsibilities of assigned tasks.

Representatives lack the skills to perform the duties and responsibilities of assigned tasks.

All representatives have knowledge or understanding of LTC consumers, facilities, services, or their management, but no prohibited ties with facilities, services, or their management.

Representatives have no prohibited ties to LTC facilities, services, or their management.

Representatives have prohibited ties to LTC facilities, services, or their management.

All representatives have knowledge or understanding of the variety of regulatory functions (licensing, survey, certificate of need, rate setting, etc.) and their effects on LTC consumers but no prohibited ties with regulatory agencies.

Representatives have no prohibited ties to any regulatory agency (licensing, survey, Medicaid, rate setting, etc.).

Representatives have prohibited ties to any regulatory agency (licensing, survey, Medicaid, rate setting, etc.).

 

Representatives have no responsibilities for Adult Protective Services (APS), nor do they serve as guardian for an unrelated resident of a LTC facility within his or her service area.

Representatives have responsibilities for APS or are guardians for an unrelated resident of a LTC facility within his or her service area.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

The program maintains a reputation as one staffed by well-prepared, knowledgeable workers familiar with the latest developments and trends and generously able to help others learn its knowledge and skills. Training is conducted in a manner developed to foster and encourage the ongoing improvement and skills of every representative of the Office.

Representatives have in-depth initial training prior to performing any duties, are assessed for competence prior to acting directly without direct supervision, and receive ongoing training and supervision to improve skills and to stay abreast of program and LTC developments.

Representatives have little or no initial or ongoing training sufficient to provide the full range of ombudsman services in a way that meets program standards.

The Office has an established procedure for terminating any representative of the Office for unacceptable job performance.

The Office has an established procedure for terminating any representative of the Office for unacceptable job performance.

The Office has no established procedure for terminating any representative of the Office for unacceptable job performance or the MOffice fails to use the established procedure in the face of unacceptable job performance.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.4 Legal Authority

Exemplary Practices

Essential Practices

Unacceptable Practices

Through education of representatives, provider groups, residents, and regulatory agencies and, when necessary, intervention by the program’s legal counsel, ombudsman legal authority has been operationalized.

The Office or state ombudsman has authority and written procedures to designate or de-designate all representatives of the Office and the host agencies of local ombudsman programs.

The Office or state ombudsman has no authority over agencies hosting local ombudsman programs, local ombudsmen (if any) or volunteer advocates. In short, there is no effective designation or de-designation process for representatives of the office.

As a result of education and legal intervention, questions or objections to the presence of Office representatives in facilities or their work on behalf of residents are extremely rare in the context of numerous visits, vigorous resident advocacy services, and strong systemic advocacy work.

Representatives of the Office are permitted suitable access to all LTC residents, facilities, and records that are subject to resident or public review and perform adequately their complaint resolution, education, and advocacy functions.

Representatives of the Office are not permitted suitable access to all LTC residents, facilities, and records that are subject to resident or public review, so as to perform adequately their complaint resolution, education, and advocacy functions.

Ombudsman legal authority is implemented through education, the intervention of legal counsel, and is appropriately and responsibly exercised so that no litigation has been brought against any representative in the context of numerous visits, vigorous resident advocacy services, and strong systemic advocacy work.

Representatives are not liable under state law for the good faith performance of duties as a representative of the Office.

Representatives may be liable individually under state law for the good faith performance of duties as a representative of the Office.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Ombudsman legal authority has been implemented and is appropriately and responsibly exercised so that no complaints of willful interference or reprisal have been made, despite numerous visits to a broad range of LTC facilities, a vibrant complaint resolution program, and a systemic advocacy agenda.

The state has provided for sanctions and applied them for the willful interference with a representative of the Office when performing assigned duties and for any retaliation or reprisal by any entity against any person who cooperates or works with a representative of the Office.

The state has not provided for sanctions nor enforced established sanctions for the willful interference with a representative of the Office while performing assigned duties and for any retaliation or reprisal by any entity against any person who cooperates or works with the Office.

 

There are no state laws, regulations, or policies that restrict the ability of the Office or its representatives to perform a mandated service or activity.

There are specific state laws, regulations, or policies that restrict the ability of the Office or its representatives to perform a mandated service or activity (e.g., a civil service policy that forbids any state employee from representing residents in involuntary transfer and discharge hearings).

Ombudsman legal authority related to the conflicts of interest in provisions for representatives of the Office and entities that select or house representatives of the Office have been implemented in such a way that challenges are rare.

The OAA provisions related to conflicts of interest for representatives of the Office and entities that select or house representatives of the Office have been implemented consistent with the recommendations found in Chapter 4.

The OAA provisions related to conflicts of interest for representatives of the Office and entities that select or house representatives of the Office have not been implemented.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Exemplary Practices

Essential Practices

Unacceptable Practices

Ombudsman legal authority has been implemented so that resident confidences have been protected and a broad range of advocacy services have been delivered to all the state’s LTC facility residents.

Ombudsman legal authority has been developed and complies with OAA provisions on confidentiality.

Specific state laws, regulations, or policies violate OAA provisions related to confidentiality (e.g., ombudsmen are mandatory reporters of elder abuse or ombudsmen are not allowed to examine resident records even with resident permission).

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.5a Resources: Financial

Exemplary Practices

Essential Practices

Unacceptable Practices

All “essential financial resource practices” are in place.

Direct ombudsman services are not limited by excessive administrative fees or charges assessed by contracting or host agencies. Assessments of reasonable administrative fees or charges are approved by the state ombudsman.

Before ombudsman funds are spent on direct services (individual resident advocacy services, education, etc.), contracting or host agency(s) extracts an administrative fee or underwrites agency administrative expenses to a degree that severely limits the ability of the representatives to deliver services.

Ombudsman funds and resources are used exclusively for ombudsman program functions.

Ombudsman funds or staff resources are used for non-ombudsman functions.

Contracting and host agencies are audited annually by an independent auditor. The audit is reviewed by the state ombudsman, the SUA, and the contracting agency.

Contracting or host agencies are not audited annually by an independent outside auditor.

The SUA and AoA assure that the “maintenance of effort” provisions of the OAA are enforced at both the state and local levels.

The SUA and AoA do not assure that the “maintenance of effort” provisions of the OAA are enforced at both the state and local levels.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Exemplary Practices

Essential Practices

Unacceptable Practices

The SUA assures that other federal and state funds (e.g., for training, elder abuse prevention and education, Title VII, insurance counseling, and volunteer training and recruitment) are made available to the ombudsman program in keeping with program needs and overall service delivery designs.

The state ombudsman cross-analyzes expenditures within and between local program entities for items related to selected service performance indicators to permit performance evaluations and financial auditing (e.g., days complaints are pending compared to number of person-hours available, visitations compared to personnel, and education events compared to mileage and brochures.)

The state ombudsman conducts no analysis of how ombudsman funds are spent and how many services are delivered.

The Office has a healthy mix of funding sources (including government, United Way, foundation, donations, and other funds) for its operation.

The program has sufficient financial resources to meet nonpersonnel needs and demands. For example, there is money for computer equipment, publications, mileage, training, and photocopying.

The program lacks the financial resources to meet nonpersonnel needs and demands. For example, there is no money for computer equipment, publications, mileage, training, and photocopying.

Representatives of the Office and its host entities are allowed and encouraged to raise funds from a variety of sources to be designated for the work of the Office and program.

 

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.5b Resources: Information Management

Exemplary Practices

Essential Practices

Unacceptable Practices

The “essential information management practices” are in place.

 

The computerized system of tracking resident complaints handled by the Office and the management information system to evaluate the performance of representatives of the Office is used to spot trends in resident concerns, to discern training needs of representatives and others, and to identify the most efficient, effective methods of providing services to residents.

There is an effective system of tracking resident complaints handled by the Office and an effective management information system to evaluate the performance of representatives of the Office. The state ombudsman and all local entity supervisors receive, at least quarterly, all the information reported.

There is no effective system of tracking resident complaints handled by the Office and no effective management information system to evaluate the performance of representatives of the Office. For example, the state ombudsman does not know how many visits are made to nursing homes, the top ten complaints handled by the Office, or total number of professional staff or volunteers.

Information from the Office’s work, integrated with comparable data from other sources, determines policy decisions about advocacy issues affecting residents and program planning for the Office.

Information from the Office’s work on behalf of residents determines policy decisions about advocacy issues affecting residents and program planning for the Office.

Data from the Office’s work does not affect policy decisions about issues affecting residents or program planning for the Office.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Exemplary Practices

Essential Practices

Unacceptable Practices

The Office shares information generated from its own resident advocacy services, without violating confidentiality, and shares public information about residents’ concerns about health, safety, welfare, and rights with regulatory agencies, resident or family councils, citizen groups, other advocacy agencies, providers, and policymakers.

The Office shares public information about residents’ concerns about health, safety, welfare, and rights with regulatory agencies, resident or family councils, citizen groups, other advocacy agencies, providers, and policymakers.

The Office does not share public information about residents’ concerns about health, safety, welfare, and rights with regulatory agencies, resident or family councils, citizen groups, other advocacy agencies, providers, or policymakers.

The Office has added elements to the federally mandated ombudsman reporting system to adequately monitor the trends and conditions specific to its state and its program.

The Office implements the federally mandated reporting system and fully reports the mandated information so that a national database is created.

Important sections of a relevant state or federal agencies do not recognize or know about the role and services of the Office. Similarly, a majority of state or federal field office personnel do not recognize or know about the role and services of the Office.

Ombudsman and regulatory agencies establish an interactive data link so that the ombudsman program has direct access to state and federal data resources.

Regular contact with regulatory agencies is limited to reacting to state regulatory agency proposals or activities in the same way the public can. All survey and certification documents are received and distributed to local office representatives for their work.

 

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.5c Resources: Legal

Exemplary Practices

Essential Practices

Unacceptable Practices

All “essential legal resource practices” are in place.

 

All components of the Office have ongoing, regular, and consistent access to specialized legal resources. Legal counsel consults regularly in case review, issues development, strategic planning, and educational efforts.

The Office and all its representatives have adequate legal counsel to: defend and assist it in the performance of all mandated duties of the Office; provide advice and counsel needed to protect the health, safety, welfare, and rights of residents; and pursue administrative, legal, and other appropriate remedies on behalf of residents.

The Office and all its representatives do not have access to adequate legal counsel to defend and assist them in the performance of all mandated duties. For example, the attorney general will represent the state ombudsman, but will not represent local staff or volunteers (who are not state employees).

The Office encourages and fosters the publication of educational materials for the training of attorneys and other legal professionals who analyze laws in ways that further the interests of LTC residents.

For purposes of fulfilling these functions, legal counsel is adequate if it is: (a) a regular and integral part of the ombudsman program; (b) knowledgeable; and (c) without conflict of interest. “Knowledgeable” means that counsel has in-depth training and experience in LTC, elder law, disability law, issues of program administration, and the legal needs of facility residents. “Without conflict of interest”

The Office has access to legal counsel but access is neither regular nor an integral part of the program. For example, the cost of legal counsel for more than occasional consultations is prohibitive in light of the financial resources made available to the ombudsman. The Office has access to counsel, but counsel is not knowledgeable or without conflicts of interest.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Exemplary Practices

Essential Practices

Unacceptable Practices

 

means that the principles stated by the committee in its Recommendation 4.4 are followed.

 

Pursuing administrative, legal, and other appropriate remedies has both individual-and system-level components. On both levels, the Office has the ability to initiate affirmative administrative, legal, or other actions on behalf of residents or their interests, through in-house legal counsel or through coordination with other legal advocacy services, such as Title III-B OAA providers, Legal Services Corporation providers, P&As, in-house counsel, state legal hotlines, pro-bono and lawyer referral programs, and contract attorneys and firms.

The Office has access to counsel for some, but not all, essential functions. For example, legal counsel is available to defend the ombudsman and to provide advice, but the program has no direct legal resources to initiate any affirmative legal action to pursue administrative, legal, or other appropriate remedies on behalf of residents (on the individual or systemic levels), to pursue administrative, legal, or other appropriate remedies on behalf of residents on either an individual or systemic level.

All legal actions using ombudsman financial resources, the Office’s legal counsel, or the authority of the Office to initiate actions in the name of residents are only to be taken with the approval of the state ombudsman.

 

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.5d Resources: Human

Exemplary Practices

Essential Practices

Unacceptable Practices

All “essential human resources practices” are in place.

 

The state ombudsman and all paid ombudsmen have no other role responsibilities. All serve in a full-time capacity as LTC ombudsmen.

An identified individual serves as the full-time state ombudsman.

No single individual serves as the full-time state ombudsman.

 

No representative of the Office has any other role or responsibilities that conflicts with the role or responsibilities of the Office.

The state ombudsman or other representative of the office has other responsibilities that present a conflict of interest with requirements of the position of ombudsman (e.g., head of Adult Protective Services).

The number of paid staff ombudsmen substantially exceeds the minimum rate of 1 full-time equivalent for every 2,000 LTC facility beds in the state.

The number of paid staff ombudsmen meets the minimum rate of 1 full-time equivalent for every 2,000 LTC facility beds in the state. These numbers presume that only facility residents are served; these staffing numbers are not sufficient to serve nonfacility health and LTC consumers.

The number of paid staff ombudsmen falls below the minimum rate of 1 full-time equivalent for every 2,000 LTC facility beds in the state.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Exemplary Practices

Essential Practices

Unacceptable Practices

 

There are enough representatives to provide effective complaint resolution and other mandated ombudsman services to people who contact the Office for services and to provide sufficient visibility for the Office.

There are not enough representatives to provide effective complaint resolution or other mandated ombudsman services to people who contact the Office for services and to provide sufficient visibility for the Office.

There are enough staff to recruit, train, and supervise all representatives, particularly volunteers.

There are not enough staff to recruit, train, and supervise all representatives, particularly volunteers.

Consistent staffing, particularly of paid staff, results in consistent high-quality services to residents.

High turnover of representatives, particularly of paid staff, eliminates the ability to provide consistent high-quality services.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.6 Office of the State Long-Term Care Ombudsman Program

Exemplary Practices

Essential Practices

Unacceptable Practices

The Office operates as a whole, unified, integrated, and cohesive program focused on serving the advocacy needs of LTC facility residents and others as assigned and separately funded. In addition to serving today’s needs, the program is in the forefront of tomorrow’s issues. In order to resolve issues, the program engages in a broad-based discussion with all players and remains focused on resident interests.

There is a functioning Office of the State Long-Term Care Ombudsman because all essential elements of the infrastructure— structure, qualifications of representatives, legal authority, and financial, information management, legal, and human resources—are in place.

There is no Office of the State Long-Term Care Ombudsman because of incapacities in the essential elements of infrastructure—structure, qualifications of representatives, legal authority, and financial, information management, legal, and human resources.

The Office has an advisory council that includes representatives of regulatory agencies and other relevant entities to assist the Office in planning and implementing its advocacy agenda and its future service delivery components.

The program has a vigorous statewide capacity to resolve individual resident concerns, whether facility based or emanating from other origins; to pursue systemic solutions to concerns affecting large numbers of residents; to provide educational services to residents, their families, and the general public about LTC residents and their rights, concerns, aspirations, and lives; and to coordinate its efforts with state and regulatory agencies.

For example, unacceptable design and capacity practices include: infrequent or no visits among B&C residents; serving individual residents largely through one central toll-free telephone service rather than having face-to-face meetings with residents; viewing the basic role of the ombudsman as a friendly visitor or a classic, neutral ombudsman rather than an advocate for LTC facility residents and limiting work to concerns raised against a facility.

 

Annual reports are distributed to the AoA and all other organizations required by the OAA and state and local laws.

Annual reports are distributed only to the AoA or fail to document a statewide program that delivers all mandated services.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.7 Individual Resident Advocacy Services

Exemplary Practices

Essential Practices

Unacceptable Practices

Using a mixture of staff or volunteer visits to facilities, brochures, posters, public service announcements (PSAs), and referrals from other agencies, the program is not only able to assist the resident with an identified problem but also consistently identifies and resolves any additional concerns.

Using a mixture of staff or volunteer visits to facilities, brochures, posters, PSAs, and referrals from other agencies, the program helps LTC facility residents in resolving identified issues or concerns.

The program has such low visibility or poor reputation that there is little chance that a resident or family member with an identified problem will locate the ombudsman program when looking for help.

The program is able to maintain a presence in facilities such that it helps residents and facilities identify items that can be improved even though these items are “accepted” by residents or the facility.

Each individual resident concern is analyzed for systemic concerns (both in each facility and across the state). Where appropriate, resolution is sought on a global basis as well as an individual one.

The program creates an individual resident advocacy service, which includes prompt response to requests for assistance, thorough exploration of issues, complete investigation of possible causes and solutions, client-directed plans for resolution strategies, and effective implementation of a variety of resolution strategies until the individual resident is satisfied. Special consideration is given to increase access to the program by residents with cognitive or physical impairments.

The program as a whole or its regional offices do not respond appropriately to requests for individual advocacy services. The failure may be due to a basic lack of skills or understanding of the steps to complaint resolution or to an attitude of advocacy avoidance. For example, a program or one of its parts or representatives may believe it is inappropriate to “rock the boat.”

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

With each individual resident advocacy service, an individual resident, family member, resident council, family council, or other entity becomes better equipped to self-advocate in the next matter.

In order to develop an individual resident advocacy service, the program has ensured that staff and volunteers are properly trained and supervised, records of activities are maintained, appropriate referrals are made, and program standards are consistently met.

The program as a whole or in part lacks the training, resources, operating practices, or authority necessary to handle individual concerns. For example, staff or volunteers do not have basic skills in complaint resolution.

Client satisfaction studies of the individual resident advocacy services program are conducted and their recommendations for program improvement are implemented.

The state ombudsman has developed a systematic and participatory approach to reviewing the work of all local programs, including standard methods of resolving individual resident’s concerns; consistent documentation of findings and actions taken; and standard methods of correcting problems within the ombudsman program.

The state ombudsman has not developed a systematic and participatory approach to reviewing the work of all local programs, including standard methods of resolving individual resident’s concerns, consistent documentation of findings and actions taken, and standard methods of correcting problems within the program.

The functions of the ombudsman program and the various regulatory agencies are clearly delineated and mutually understood.

All sections of relevant state and federal agencies recognize and know about the role and services of the Office and readily cooperate with requests for information from the office and the public. Likewise, the ombudsman program responds to appropriate referrals and requests for assistance from these agencies.

Important sections of relevant state or federal agencies do not recognize or know about the role and services of the Office. Similarly, a majority of state or federal field office personnel do not recognize or know about the role and services of the Office.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.8 Systemic Advocacy Work

Exemplary Practices

Essential Practices

Unacceptable Practices

The program’s systemic advocacy agenda includes items to improve the lives of residents and not merely to resolve identified concerns or problems in the LTC system. For example, the program works on improving the skills of residents in conducting council meetings, on improving reimbursement systems so that families can and will provide quality services, or on improving the health care system’s overall standards of care.

The state ombudsman develops a systematic and participatory approach for local programs to analyze their individual resident advocacy service work to identify systems issues. The state ombudsman then analyzes the same data on a statewide level.

Using such information, the program establishes a systems agenda for work by the entire program and describes it in an annual report. Under the direction of the state ombudsman, the program uses a variety of methods and broad coalitions of groups to pursue resolution of the identified systemic concerns.

The program (state and local) does little or nothing to address concerns affecting a large number of residents. For example, the program rarely, if ever, comments on proposed changes in state or federal laws, regulations, or policies; directly seeks changes, clarifications, or improvements in state or federal laws, regulations, or policies; files complaints with responsible agencies about the operations of state or federal programs; or involves or assists residents, their families, citizens organizations, other agencies, or the public in securing changes in state or federal laws, regulations, or policies.

 

The program consistently comments on proposed changes in state or federal laws, regulations, or policies; directly seeks changes, clarifications, or improvements in state or federal laws, regulations, or policies; files complaints with responsible agencies about the operations of state or

The program (state and local) does not produce an annual report that discusses and makes recommendations for changes in state or federal laws, regulations, or policies.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

 

federal programs; or involves and assists residents, their families, other agencies, or the public in securing changes in state or federal laws, regulations, or policies.

 

The program’s systemic advocacy is focused on a variety of LTC facilities, residents, and all aspects of residents’ lives and concerns. The work is coordinated with others, including those organizations not usually interested in LTC issues, so that broad-based coalitions, rather than the ombudsman program alone, seek systemic change.

The program’s systemic advocacy is focused on a variety of LTC facilities, residents, and all aspects of residents’ lives and concerns. The work demonstrates a willingness to take on vested interests of all kinds and bring to bear persistence, creativity, and multiple constituencies.

The program’s systemic advocacy does not focus on a variety of LTC facilities, residents, nor all aspects of residents’ lives and concerns. For example, the program’s work is targeted only on nursing home residents and their concerns with a particular owner, but ignores the inadequacies of the licensing or certification agencies, or the eligibility standards of Medicaid.

The Office has ongoing interactions with the full range of regulatory agencies with specific agendas to discuss plans for future actions at “pre-decision points,” to plan and conduct joint trainings, to coordinate efforts wherever possible, and to maximize the different strengths, roles, and talents of each agency and the Office.

The Office has regular contact with regulatory agencies as required by the HCFA Medicare and Medicaid survey protocol. The Office also has the same type of contact afforded the public. This includes: ombudsman participation in committees and work groups related to LTC; and submission of comments on all proposed administrative policies that affect LTC facility residents.

The Office experiences open, ongoing hostility or conflict with one or more state regulatory agencies. There is no sharing of information, strategies, or goals between any segment of the Office and the management of the regulatory agencies. Each sees their relationship to the other as limited to protecting their agency or program or the residents from the other.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

Exemplary Practices

Essential Practices

Unacceptable Practices

The Office works to foster direct resident participation in the regulatory agency’s program and policy efforts and routinely advises the public (particularly residents, families, and citizen advocacy groups) of any opportunities for public comment or other participation in the regulatory process.

In an attempt to resolve conflicts with regulatory agencies, the Office holds open discussions with representatives of the relevant state agencies before any new systemic advocacy measures are taken.

 

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×

TABLE 5.9 Educational Services

Exemplary Practices

Essential Practices

Unacceptable Practices

In conjunction with its systemic advocacy agenda, the program initiates and develops educational brochures, pamphlets, posters, PSAs, newsletters, and other written materials to advance its agenda.

Responding to requests, the program (state and local) produces and distributes educational brochures, pamphlets, posters, PSAs, newsletters, and other written materials that answer the questions asked by LTC facility residents, families, and others or that explain the services of the program.

The program (state and local) produces few, if any, educational brochures, pamphlets, posters, PSAs, newsletters, or other written materials that answer the questions asked by LTC facility residents, families, and others or that explain the services of the program.

In conjunction with its systems agenda, the program (state and local) initiates and presents educational programs for residents, families, citizen organizations, facility staff, regulatory staff, policymakers, or the general public that answer their questions about health care in LTC facilities or the interests of residents.

Responding to requests, the program (state and local) presents educational programs for residents, families, citizen organizations, facility staff, regulatory staff, policymakers, or the general public that answer their questions about health care in LTC facilities or the interests of residents.

The program (state and local) presents few, if any, educational programs for residents, families, citizen organizations, facility staff, regulatory staff, policymakers, or the general public that answer their questions about health care in LTC facilities or the interests of residents.

 

The state ombudsman adequately responds to the informational and educational requests of local ombudsman programs.

The state ombudsman does not adequately respond to the informational and educational requests of local ombudsman programs.

Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
×
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×
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×
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×
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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Suggested Citation:"Effectiveness of the State Long-Term Care Ombudsman Programs." Institute of Medicine. 1995. Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act. Washington, DC: The National Academies Press. doi: 10.17226/9059.
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