a fairly affluent clientele; others adjust their rates to the relatively low SSI reimbursement levels.

Implications for ombudsman work are many. Because in almost all states the Medicaid reimbursement rate is lower than the private-pay rate, ombudsmen have become involved in Medicaid discrimination issues, where nursing facility residents or their families believe that a resident receiving Medicaid has been transferred inappropriately in the facility, discharged to a hospital and not taken back, or generally treated worse than private-pay residents. Ombudsmen have also advocated for systemic reform on the amount of money residents are allowed to retain for personal needs. Finally, because of concerns among many sectors of society, including policymakers, providers, and some of the general public, to contain costs, particularly through Medicaid reimbursement rates, ombudsmen operate in an atmosphere of resource scarcity. This scarcity tempers individual advocacy for the kind of service and lifestyle that might be most desirable for the consumer, and at the same time it underscores the need for systemic advocacy. Society faces the triple challenges of assuring that LTC services are delivered as efficiently as possible, designing new services that will meet the preferences of elders and their families, and assuring the quality of these services.

QUALITY OF CARE AND QUALITY OF LIFE

“Quality of care” and the broader concept “quality of life” are sometimes contrasted in health care discussions. Some argue that, if people are forced to relocate their residence in order to receive health-related services in a cost-effective manner, then the providers of those services are bound to hold themselves accountable for quality of life as well as quality of care. In fact, the Nursing Home Reform Law of 1987 requires nursing facilities to do just that.

Quality of Care

In comparison to hospitals, nursing facilities and, particularly, B&C homes are low-technology environments. Nevertheless, these settings (including subacute care units in nursing facilities) provide medical and nursing care that must still meet a standard of technical adequacy. If various medical and nursing protocols (e.g., for administration of medications, management of catheters, monitoring of specific diagnostic conditions, skin care of bed-bound people) are ignored, outcomes for residents will suffer.

As early as the 1970s, federal demonstration projects in nursing facility quality assurance (Kane et al., 1979) established protocols for adequate care



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