One element of the charge to the Institute of Medicine study committee, therefore, involved the issue of resources, and this chapter reports on the committee’s examination of this question. In this, the committee confined its discussion to resources for bringing the program into full implementation and compliance with today’s statutory mandate for nursing facilities and B&C homes. It did not attempt to forecast the level or type of resources that might be needed to fulfill any possible expansion of the program (with respect to LTC, to the elderly, or to the nation as a whole secondary to comprehensive health care reform) —matters taken up in Chapter 7.

ADEQUATE PROGRAM PERFORMANCE

The committee has been impressed by the extent to which states vary in the effectiveness or productivity of their ombudsman programs and in the availability and utilization of resources. Clearly, a judgment about the adequacy of program funding and resources cannot be made without some reference to indices of program output and performance. Furthermore, Congress intended the ombudsman program, if the specifications in the Older Americans Act (OAA) are to be taken at face value, to be more than simply a program that responds to LTC residents’ complaints. It has other mandated functions, such as staff and volunteer training and systemic advocacy. As discussed in Chapter 5, however, performance measures can be difficult to define conceptually and even more challenging to measure in any systematic, quantifiable way. In view of the paucity of accurate data for assessing compliance, the committee developed a list of elements of infrastructure and function that must be present for any state program to achieve effective output (see Tables 5.25.9).

Relatively crude indicators of program quality are available, however. Some reflect so-called structural measures (numbers of full-time equivalent [FTE] staff), others relate to the processes and activities of the program (paid staff per numbers of LTC beds), and others pertain to outcomes of those processes (the percentage of complaints registered that are fully resolved or peer nominations of “successful” programs). These measures of program adequacy must be set against existing program dollars to determine whether present levels of funding can reasonably be expected to produce the desired levels of program activity and outcomes.

Possibly the most detailed use of such measures is contained in a recent federal review of the ombudsman program. In 1991 the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS) issued three reports (1991a,b,c) based on a national inspection of the programs of all states, the District of Columbia, and Puerto Rico. Using



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