Even individuals who under normal circumstances have no difficulty expressing their opinions or making their needs known may need an intermediary or proponent should they fall ill or be confronted with an inadequate or nonresponsive system of health care. The need for advocacy may vary over time for a given individual, depending on many factors—his or her physical, cognitive, and emotional health, underlying beliefs and desires about relying on outside assistance, and the complexity and quality of the systems of care to be confronted. For example, an individual who has a broken hip and is trying to arrange for home-delivered meals for a few weeks is much less likely to need an advocate than is an individual with severe cognitive impairment who is trying to appeal an involuntary transfer from a nursing facility.

When the LTC ombudsman program first began in the early 1970s, its efforts were targeted at nursing facility residents because they were viewed as among the most vulnerable consumers, that is, as persons who were relatively “disempowered” and living in very complex “total” institutions. The ombudsman program was viewed as a means of providing a voice through which those residents could resolve problems and experience an optimal quality of life. A few years later, the program expanded to serve board and care (B&C) home residents, since this population was also relatively disempowered and living in a myriad of residential settings of varying character and quality. In this context, it is important to stress that core elements of the ombudsman program to date have been quite facility-oriented. In addition, by federal mandate, the basic target population for the program remains the elderly (i.e., persons 60 years of age and older).

Now, almost two decades after the program first began, it is clear that the health care and LTC systems have undergone sweeping changes—an evolutionary trend that doubtless will continue. The number of vulnerable consumers who are now living outside of residential facilities and who are using increasingly complex systems of care to maintain their independence is unknown. Some of these consumers are indistinguishable in their cognitive or physical impairments from nursing facility residents.

Therefore, the proponents of an expanded ombudsman program foresee a future need for similar ombudsman-like activities and assistance for at least some of the noninstitutionalized elderly population, even though those tasks would no longer be oriented directly to LTC facilities. Moreover, the changing demographics of the U.S. population (the “graying of America”) and patterns within the elderly subset itself (e.g., the increase in numbers of the oldest old) lead some experts and most committee members to predict rising needs for ombudsman-like interventions and programs. Thus, predicting who will need advocacy is essential when considering possible expansion of the LTC ombudsman program.

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