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



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

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

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

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

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

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Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act 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: interest groups within the political process that are antagonistic toward the ombudsman program;

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Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act the bureaucratic nature of most of the institutions within which the ombudsman program must work; 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; socioeconomic or cultural conflicts among residents or between providers and residents; and 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:

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

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

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Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act 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 5.2–5.9 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.

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

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

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

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

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

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Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act 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.”

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

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

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

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

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

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