The subject of this study, the long-term care (LTC) ombudsman programs, came about two decades ago in response to the widespread perception that there was a crisis in nursing home quality. Despite laws and regulations to address these concerns and to protect nursing home residents, scandals involving poor and negligent care were surfacing. The mission of the ombudsman program was twofold: while advocating for broad policy changes, ombudsmen were to help resolve the very real problems faced by real people in nursing facilities. In 1981, the program's mission was extended to cover the concerns of residents of board and care facilities.
Over the past two decades, quality assurance activities for nursing facilities have multiplied. In particular, a 1986 Institute of Medicine study, Improving the Quality of Care in Nursing Homes, made far-reaching recommendations for federal policy in this area. As a result of that study and subsequent legislation in 1987, several policies have been adopted to address problems in nursing home quality. Phasing in these changes is a slow and lengthy process that is far from complete. Although ombudsmen do not bear the responsibility of implementing these changes, much of their activity for the past decade has been concerned with and shaped by the anticipation, inception, and implementation of these new laws and regulatory reforms.
In the early 1990s, policymakers--at the urging of ombudsmen themselves--concluded that an in-depth examination of the program was warranted to examine its present strengths and weaknesses and assess its potential for future contributions. The Congress of the United States directed the Assistant Secretary for Aging of the Administration on Aging (AoA) to conduct a study of the state LTC ombudsman programs. AoA subsequently contracted with the Institute of Medicine to perform the study.
The effectiveness of the current program is not well understood, and its potential for having a meaningful impact beyond the relatively narrow settings of LTC facilities is not known. Nevertheless, the program serves as a model for several proposed "health care ombudsman" programs. Consequently, many experts and parties interested in the LTC arena, as well as those concerned more broadly with comprehensive health care reform, will look to this study for guidance. Can the structure, activities, and accomplishments of the present LTC ombudsman program be successfully generalized to other settings, populations, and challenges?
This report is the culmination of a 12-month effort by a committee of 16 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. The charge to this committee was to assess the LTC ombudsman programs' performance and, when appropriate, to make recommendations on public policy strategies by which the program can better achieve its objectives.
The committee engaged in several factfinding activities, including: site visits to six states; seven commissioned papers; structured, systematic contacts with directors of state units on aging, state and local LTC ombudsmen, LTC physicians, and grassroots advocacy groups; a one-day invitational symposium; a public hearing; two "open-mike" sessions at national professional conferences; discussions with four national associations of LTC facility providers; and a technical panel that was convened twice and called upon as needed throughout the course of the study.
The committee concluded that the ombudsman program serves a vital public purpose and merits continuation with its present mandate. Through advocacy efforts at both the individual resident and the system levels, paid and volunteer ombudsmen uniquely contribute to the well-being of LTC residents--complementing, but not duplicating, the contributions of regulatory agencies, families, community-based organizations, and providers. To underscore this commitment to the mission of the program, the committee sets forth several recommendations that are intended to bring the programs in compliance with the legislated mandates; build a nationwide database on key structure, process, and outcomes measures for the program; enhance each state's ability to operate a unified statewide Office of the LTC Ombudsman; stimulate and guide needed research; and encourage leadership from the federal government.
The committee conjectured about the future of the ombudsman program in light of the health care reform movement and recent trends in health care and LTC. For more than a decade, virtually all components of the health care delivery system have undergone restructuring and have experienced the "ripple" or "domino" effects of Medicare and other policy changes. The process of change holds significant clues about the future direction of health care and implications for the LTC ombudsman program.
The increasing growth and dominance of managed care organizations raise complex issues for LTC. Among the more pressing are: the relationship of LTC facilities and services to managed care organizations, how cost-containment strategies will be implemented in LTC settings, and how they will influence the organization, scope, and delivery of care. Additionally, the nature and scope of community-based service delivery has altered to such an extent that traditional conceptions of post-hospital care and LTC are no longer realistic. Average lengths of stay in nursing homes are decreasing and the nursing home is shifting in some respects from a long-term residence to a sub-acute facility. The home care sector is experiencing considerable growth, attributable in part to advances in medical technology that have led to the transfer of "high-tech" medical procedures from hospitals, clinics, and nursing facilities to the home setting.
Increased demand for ombudsman-type services will likely rise as managed care and cost-containment strategies play a more prominent role in decision making about who does--or does not--enter nursing facilities and other LTC facilities, and as more LTC services are provided in home- and community-based settings. If the ombudsman of the future serves only residents of LTC facilities, many vulnerable persons needing the services offered by an ombudsman will be denied access. The extent to which the LTC ombudsman program is poised for integration into the frameworks of the larger, restructured health care system and coordinated with other forms of consumer advocacy depends in part on how successfully the present program fulfills it mission. The committee's recommendations are intended to strengthen the program's capacity to carry forth with its current mission and prepare for the real problems that will be faced by real people in the future.
Carroll L. Estes
Chair
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