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;



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