• Intermediate sanctions, such as fines, were recommended, and a new series of rules on enforcement procedures developed (although the final rules have not yet been published).

In 1987, these changes began to be phased in—a slow and lengthy process that is far from complete. Although the Health Care Financing Administration of the Department of Health and Human Services (DHHS) at the federal level and various state certification agencies bore the responsibility of implementing these changes, LTC ombudsman programs have been active in advocating for changes, monitoring the conduct of regulatory reform, providing training and consultation to state surveyors and the staff at individual facilities on quality of life and rights issues, training at the individual facility level, and informing residents and families about the reform. Thus, ombudsman activities for the past decade have been concerned with and shaped by the anticipation, inception, and implementation of new laws and regulatory reforms.


The LTC ombudsman program is relied on to address and solve many of the ills that presently afflict the LTC sector in this nation. Indeed, the program currently serves as a model for “health care ombudsman” programs that may be deemed desirable (or necessary) as broader health care reform moves forward in the United States. However, the effectiveness of this program is not well understood and neither is its potential for providing a meaningful impact beyond the relatively narrow settings it currently serves.

Understandably, policymakers—at the urging of ombudsmen themselves—concluded that a more in-depth examination of the program was warranted, in order to examine its present strengths and weaknesses and its potential future contributions. To obtain this examination, the Congress of the United States directed, in the 1992 reauthorization of the OAA, that the Commissioner on Aging of the Administration on Aging (AoA) conduct a study of the state LTC ombudsman programs.

This report is the culmination of that work, which commenced in October 1993. The IOM appointed a 16-member expert committee chaired by Carroll L.Estes, Ph.D., of the University of California, San Francisco. (For a complete list of committee members and their affiliations see the committee roster on page iii. For biographical sketches of the committee members, see Appendix D.) The committee comprised individuals recognized for their expertise in LTC, medicine, medical sociology, health care policy and research, clinical research, health law, health care administration, state government policy and program administration, consumer advocacy, public health, voluntarism, and the LTC ombudsman program.

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