certification, and survey processes for home health agencies. In addition, public and private guardianship and conservatorship policies are meant to ensure that those unable to make decisions have an agent to act in their best interests.

Of course, all these mechanisms have strengths and limitations. Case management programs are variable in their focus and ability to truly serve as advocates. APS caseloads are large, and the responsibilities of the protective service worker is a rather narrow legal one. Home care complaint hotlines are for the most part poorly publicized and underutilized. Licensure and certification are only as good as the motivations of surveyors and certification programs and the strength of public requirements, regulations, and sanctions; these factors vary significantly across states. Guardianship programs have been criticized as being perfunctory. It is unclear, therefore, whether the solution to these problems is to strengthen one or more of the existing mechanisms, combine and strengthen advocacy functions into a new structure, or create an ombudsman as a superordinate, general operation.