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Correspondence: Address correspondence to Carroll L. Estes, PhD, Institute for Health & Aging, University of California, San Francisco, 3333 California Street 340, San Francisco, CA 94118. E-mail: cestes{at}itsa.ucsf.edu
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Key Words: Long Term Care Ombudsman Program • Resources • Organizational placement • Organizational autonomy • Long-term care quality • Perceived effectiveness
Currently there are LTCOPs operating in all 50 states, the District of Columbia, and Puerto Rico. In fiscal year 1999 there were 587 local and regional ombudsman programs (Administration on Aging [AoA], 1999). Most state programs utilize volunteers in addition to paid staff. The majority of programs operate within State Units on Aging (SUAs), which are either independent or part of a larger state umbrella agency. In addition, several programs are operated by other state agencies, legal services agencies, or nonprofit organizations. All LTCOPs receive federal funding, and most receive additional funding at state and local levels. In fiscal year 1999, ombudsman program expenditures from all sources totaled approximately $51 million nationally. Approximately 61.3% of the funding was from federal sources (most often Title III of the OAA), 26.4% was from states, and 12.3% was from local funds.
Background
In the first two decades of the ombudsman program (1972 to the late 1980s), research concerning it was relatively sparse (Buford, 1984; Monk, Kaye, & Litman, 1984). By the early 1990s, continuing nursing home scandals and increased awareness of the LTCOP prompted governmental studies by the Office of the Inspector General ([OIG], 1991a, 1991b, 1991c), AoA/OIG (1993), and the General Accounting Office ([GAO], 1992), as well as the influential 1995 Institute of Medicine (IoM) evaluation of the Long Term Care Ombudsman Programs of the OAA (IoM, Harris-Wehling, Feasley, & Estes, 1995). The 1991 OIG study identified characteristics of the most successful LTCOPs, including high visibility, frequent facility visits, and expeditious handling of complaints (OIG, 1991a, 1991b, 1991c; OEI-02-90-02120). The IoM report, Real People, Real Problems, investigated issues such as state compliance with program mandates, conflicts of interest at the organizational level of interest, individual conflicts, willful interference and conflicts related to provision of legal counsel, and the effectiveness of LTCOPs (IoM et al., 1995).
Until the mid-1990s, research focused primarily on single state and local program studies or historical–policy pieces (Cherry, 1991, 1993; Nelson, Huber, & Walter, 1995; Netting, Huber, & Kautz, 1995; Netting, Huber, Paton, & Kautz, 1995). By 1995, the AoA's National Ombudsman Reporting System (NORS) was in place, providing the first readily accessible 50-state data and allowing comparisons (both over time and multistate) on program outputs and outcomes (AoA, 2000; Huber, Borders, Netting, & Kautz, 2000)—although with notable data limitations such as inability to link or track complaints by facility and location. Three national entities have raised the visibility of LTCOP issues for research: the National Association of State LTC Ombudsman Programs, which advocates for positions that benefit residents and responds to information requests; the National Ombudsman Resource Center, which participates in training and information dissemination; and the National Association of State Units on Aging (NASUA), which represents the SUAs that are responsible for designating the state ombudsman and is a collaborative partner in the National Ombudsman Resource Center—most recently facilitating the workgroup on LTCOP outcomes measurement (NASUA, 2000).
From the late 1990s to the present, research publications on the LTCOP increased markedly, including a series of AoA NORS reports (AoA, 1999, 2000); more OIG reports (1999a, 1999b), including one focused on nursing home conditions in 10 large states with recommendations to strengthen ombudsman programs; and gerontological articles (see reference list). A number of the latter explore methodological issues and data limitations. For example, Netting, Paton, and Huber (1992) identified substantial variations and problems in the early AoA complaint reporting system; Huber and colleagues (2000) showed the import of contextualizing data in order to minimize inaccurate conclusions; and Huber, Borders, Badrak, Netting, and Nelson (2001) described the potential problems and penalties with self-ratings (both positive and negative) by ombudsmen in research.
Multiple studies have investigated dimensions of the effectiveness of LTCOPs and documented variations in program structure, other characteristics, and operations (Cherry, 1991 and IoM et al., 1995, to name only a few); others have documented the relationship of the presence of an ombudsman in particular types of facilities (e.g., Intermediate Care Facilities) to quality measures of nursing care (Cherry, 1993). Other studies focus on the effects of different organizational arrangements, such as whether the LTCOP is inside or outside the SUA or area agency on aging (AAA). One such study of local LTCOPs in a single state found differences in the effectiveness in that programs not in AAAs both verified a significantly higher percentage of complaints and resolved a significantly greater percentage of complaints to the satisfaction of the resident or complainant than those located within an AAA (Huber, Netting, & Kautz, 1996). The authors of that study suggested that the discrepancy may be due to different emphases of the two program types: Those within AAAs (which are planning and coordination agencies focused on systems development) emphasize resident rights and administrative–systemic issues, whereas non-AAA programs emphasize resident care and quality of life issues. The 1995 IoM study also identified LTCOP organizational placement as key in understanding "conflicts of interest" (both real and perceived), potentially impeding program effectiveness, citing debates as to whether the state LTCOP is more or less effective when it is situated within or outside a state agency. LTCOP "autonomy" has been described as essential to the program's ability to meet its statutory requirements to fully represent LTC residents, to freely speak with the media, policymakers and legislators, to have independent legal counsel, and to participate in policy and operational discussions with other agencies (IoM et al., 1995). The National Association of State LTC Ombudsman Programs (1998) has incorporated the principle of independence of the ombudsman program and autonomy as a core element required for effectiveness in representing residents.
Other researchers have looked at the relation of volunteers to efficacy, including Netting and colleagues (1995), who found significant differences in complaint resolution by volunteer and paid ombudsmen. Keith (2000, 2001a, 2001b) has contributed analyses on the role, characteristics, and efficacy of volunteer ombudsmen in LTC facilities and their interrelationships to one another (e.g., the import of support of facility administrators and residents to volunteer efficacy).
An important recent study (Huber, Borders, Badrak, et al., 2001) operationalized exemplary practices proposed in the IoM report (1995) by developing 10 "infrastructure component scales" for local LTCOPs, which showed improved compliance over time (1996 and 1999) on 9 of 10 scales. One scale, "structure of the local ombudsman program" addresses (through subscale measurement) key issue areas of "local autonomy" and "resources." Other studies illustrate the import of collecting particular types of data in relation to the LTCOP (e.g., resident characteristics such as race and gender)—finding, for example, lower complaint resolution rates for minorities, although higher complaint verification rates (Huber, Borders, Netting, & Nelson, 2001).
Building on this prior work, progress has been made both toward (a) the development of outcome measures (NASUA, 2000) and (b) tools to measure performance and program compliance of LTCOPs with national standards (Huber, Borders, Badrak, et al., 2001).To date, the development of the Huber, Badrak, Border Scale is the most empirical effort to address the IoM's recommendation to "develop and implement an objective method to assess compliance of state LTCOP programs" (IoM et al., 1995, p. 155). Huber and her colleagues' work is designed to assess local ombudsman program compliance that, when used at different points in time, can also provide meaningful data on change.
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The framework is consistent with a traditional logic model of research on program outcomes (NASUA, 2000; United Way of America, 1996, p. 38) in which perceived effectiveness is treated as an outcome or dependent variable. Various other variables—broadly classified as environment or context, inputs, and outputs—are examined for their association with the dependent variable and, where relevant, in association with one another. Examples of the environment or context variable are supportive political and social climate and organizational autonomy. LTCOP inputs include funding per LTC bed; ratio of LTC beds per ombudsman; volunteers per LTC bed; and measures of sufficient funding, sufficient staff, and sufficient volunteers. Outputs include percent nursing facilities visited. The outcomes are perceived state LTCOP effectiveness along several dimensions (overall effectiveness and effectiveness in complaint investigation, community education, resident and family education, work with nursing facilities, work on legislative administrative advocacy and policy, among others).
The research questions explored in this article are as follows.
First, what is the overall effectiveness (self-rated) of state LTCOPs? What is the perceived effectiveness of state LTCOPs in meeting the statutorily mandated requirements in (a) complaint investigation, (b) community education, (c) resident and family education, (d) monitoring laws and regulations, and (e) legislative, policy, and administrative advocacy?
Second, what factors are associated with the perceived effectiveness of state LTCOPs? Is there adequacy of resources? Does organizational placement permit autonomy? Is there a relationship with other agencies?
Researchers conducted telephone interviews with ombudsmen from the 50 states, Washington, DC, and Puerto Rico during a 4-month period in 2000. A single interviewer conducted telephone interviews lasting 45 min to 1.5 hr in order to enhance reliability of survey administration. All (100%) state LTCOPs participated in the study, with 46 interviews conducted with the state LTCOP director and 6 conducted with representatives of the state LTCOP (codirectors and assistant directors).
The questionnaire incorporated both closed- and open-ended items. Many items were factual questions about the activities of the state LTCOP (e.g., Question 7a on percent of different types of facilities visited), whereas others were perceptual (e.g., Question 4 on the effectiveness of the state LTCOP). Survey questions were generated based on a thorough review of data collected, issues raised, and recommendations set forth by the 1995 IoM report (IoM et al., 1995), and other relevant literature on the LTCOP (see Background). The survey instrument was reviewed and revised with the input of an advisory committee and a focus group of national experts, and it was revised again following a pretest with three former LTC ombudsmen.
The present research is a descriptive study focused on factors associated with the self-rated effectiveness of state LTCOPs. The primary telephone survey data reported here on program effectiveness and potentially related dimensions are self-ratings by state ombudsmen. The effectiveness data are the perceptions of state ombudsmen who have primary responsibility for the statewide program and to oversee, train, and assist local ombudsmen. The local ombudsmen are the ones who actually perform the complaint investigation at the level of the individual residents of LTC facilities.
Although the research was not designed to test cause and effect, some survey questions asked respondents to describe how certain variables (e.g., structural location and resources) affected their ability to do various elements of their job. These perceptions of causal links, which are relevant to understanding perceptions of effectiveness, are included in the analysis. For the analysis, the researchers relied on the prior work of the IoM Committee (IoM et al., 1995) concerning not only the major areas seen as relevant to effectiveness but also to the hypothetical causal links between various program characteristics and the study's measures of effectiveness. The analysis was also guided by the aim of understanding more about a variety of factors associated with resource adequacy, organizational autonomy, and relationships of the LTCOP with others.
Although this study reports on the self-rated assessments of overall effectiveness, as well as on specific types of effectiveness and factors related to them, the study triangulates data sources by utilizing the only other national data set for the LTCOP—the NORS data. This is a major strength of the present study. Statistical tests were used to analyze the associations between various elements of program effectiveness (from self-rated reports) and other program data collected in the telephone survey and the NORS.
Study Limitations
Study limitations are that perceived effectiveness is subject to the potential biases of self-ratings in general, and that state-only LTCOP respondents were surveyed. Nevertheless, given the absence of a systematic national evaluation of outcomes or impact evaluation of the LTCOP, the reports of state ombudsmen about their activities, their ability to fulfill program requirements, and their perceived effectiveness are valuable and informative in their own right.
Another limitation is that study investigators were not able to interview other potential respondents beyond the universe of the state LTCOPs. Additional perspectives and insights would have been gleaned if it had also been possible to interview LTC residents and their families, local ombudsman programs, SUAs, AAAs, policymakers, the nursing homes, advocacy or citizen groups, and other entities such as licensing and certification. Another limitation is actually in the NORS data, which are required by and generated for the AoA. The data consist of a compilation of information generated from the local and state levels, which is then aggregated internally for each state. This process in itself may compound an unknown potential of existing errors contained in the NORS.To date, there are no known empirical studies of the reliability and validity of the NORS data. The NASUA (2000) workgroup on LTCOP outcome measures acknowledges limitations in the NORS, but it considers it an essential data source for outcomes research, as have other scholars. Finally, the NORS data and the telephone survey utilized in the analysis were not collected at the exact same time period; rather, they were proximate in time (i.e., 9 to 12 months apart),with the NORS data for fiscal year 1999 and the telephone survey data for 2000.
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that the objectives of the LTC Ombudsman Program, as specified in the Older Americans Act and its various amendments are met to the maximum extent possible. ... [T]he effective ombudsman represents the interest of the residents ... first, last, and always—before the interests of governmental agencies and seeks ... remedies to protect the health, safety, welfare and rights of the residents of LTC facilities. (p. 131)
This concept of effectiveness is very complex and its comprehensive investigation would require a large national research evaluation that is well beyond the scope of the current project. More specifically, in the present study, state LTCOPs were not only asked to give self-ratings of efficacy but also to answer questions about their state LTCOPs from a fixed list of 16 factors that appear relevant to effectiveness, based on IoM and other literature (e.g., IoM et al, 1995; Keith, 2001b). In addition, respondents were asked to identify any other factors that they deemed as relevant to their effectiveness. Thus, as noted, effectiveness as reported here is self-rated effectiveness from the perspective of the head of the state LTCOP.
When asked to rate the overall effectiveness of their LTCOP at the state level, ombudsmen are generally positive (Table 1). Almost one-third rated their programs as "very effective" (30.8%), whereas nearly two-thirds (63.5%) rated their programs as "somewhat effective." No state ombudsmen rated their programs as "very ineffective." When state ombudsmen are questioned about individual factors that may contribute to the effectiveness of their state LTCOPs from a closed list of 16 items (Table 2), the top five most often cited areas that characterize their state programs are their ability to represent the interests of residents to most state agencies (100%), good relationships with Licensing and Certification (96.1%), the Health Care Financing Administration (93.2%), and the LTC industry (88.2%); and a uniform state database (86.8%).
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NORS data for fiscal year 1999 show that ombudsmen nationwide opened 147,340 cases and closed 130,255 cases involving 215,650 individual complaints. Of these complaints, 80.1% originated in nursing home settings, 17.6% in board and care or assisted living facilities, and the remaining in nonfacility settings. Three-fourths (74.3%) of nursing home complaints and 68.5% of board and care complaints were resolved or partially resolved to the resident or complainant's satisfaction (AoA, 2000).
The following section reports study findings organized around three prominent factors identified by the 1995 IoM study as influencing the effectiveness of LTCOPs, namely, the adequacy of resources, the organizational placement or autonomy of the program, and the relationship with other agencies.
Adequacy of Resources
Total ombudsman program expenditures for all states from all sources for fiscal year 1999 were approximately $51 million (NORS; see Table 4), reflecting an increase of almost $4 million from the previous year. In the 2000 telephone survey, more than one-third (38.8%) of state ombudsmen reported an increase in their budgets from the previous year (Survey Question 31). These budget increases had the effect of increasing resources, salaries, and training materials for ombudsmen and volunteers; increasing the number of staff; increasing the quality and quantity of services available for residents; and expanding the volunteer program (Survey Question 31a). More than one-fourth (28.8%) of the state ombudsmen reported a change in the composition of funding sources in the past 3 years, primarily as a result of increased funds from the state (Survey Question 32 and Question 32a). Reasons for the change in funding sources include legislative activity and renewed commitment by policy makers, advocacy by local ombudsmen, and utilization of the 1995 IoM report recommendations to obtain more funding (Survey Question 32b).
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When asked to estimate the amount of additional annual funding their state LTCOP would need to carry out currently neglected requirements, 38.7% estimated $200,000 or less; 32.3% estimated from $250,000 to $700,000; and 29% estimated over $750,000 (Survey Question 29d). According to the state ombudsmen, major obstacles to obtaining this funding included the political climate and perception of the ombudsman program and the state fiscal situation and legislative process (Survey Question 29e).
In terms of staffing, NORS data indicate an overall increase of 4.8% of paid full-time equivalent (FTE) program staff between fiscal year 1998 and fiscal year 1999. In the telephone survey, 40.4% of state ombudsmen reported an increase in paid full-time (FT) or FTE staff in the past 2 years, most prominently in direct services (21 states reporting), but also in administration (3 states), legal assistance (1 state), and volunteer coordination (1 state; see Survey Questions 33 and 33a). More than half (51.9%) of state LTCOPs reported no change in the number of FT or FTE staff, and 7.7% (4 states) reported decreased staff. Although staffing levels have improved somewhat over the past few years, nationwide in fiscal year 1999 there were 2,801 beds per paid FTE staff (NORS; see Table 4). However, the average state had 3,062 beds per paid FTE staff. This higher number accounts for the states that have very large ratios and thereby skew the nationwide ratio (i.e., Florida, 8,638; Iowa, 13,135; Nebraska, 11,161; Oregon, 6,229). With the exception of Florida, these states with high staff-to-bed ratios have relatively few LTC facility beds compared with some of the larger states. The residents of these states are therefore underrepresented in the nationwide ratio (2,801) but overrepresented in the average of state ratios (3,062).
Staffing shortages have been somewhat alleviated in several states by strengthening the presence of volunteers. Most state ombudsmen (91.5%) reported that the number of volunteers contributes to the effectiveness of their local programs (Survey Question 11), but only 22.2% of state ombudsmen believed they have a sufficient number of volunteers in their program (Survey Question 5). NORS data show that numbers of trained or certified volunteers have increased even more dramatically (19.6%) from 1997 to 1999 (i.e., from 6,795 in fiscal year 1997 to 7,359 in fiscal year 1998 to 8,451 in fiscal year 1999). According to telephone survey data, more than half (54%) of state ombudsmen reported an increase in the number of volunteers in the past 2 years (Survey Question 34). Most of these volunteer increases occurred in direct services (27 states so reporting).
Our analysis of NORS data for fiscal year 1999 indicates that ombudsman program expenditures per LTC bed are significantly and positively associated with the ratio of LTC beds per FTE ombudsman (p <.001; Table 5). In addition, ombudsman self-reports indicate that sufficient funding is positively associated with sufficient staff levels (p <.001), sufficient volunteers (p =.008), adequate methods of communication (p =.008), and perceived effectiveness of work with nursing facilities (p =.008; Table 5). In terms of NORS staffing data, the ratio of LTC beds per FTE ombudsman staff is positively associated with the percentage of nursing facilities that are visited per year (p =.009). Also using NORS and telephone survey data, we learn that the ratio of volunteers per LTC bed is significantly and positively associated with how ombudsmen rate the effectiveness of their work with nursing facilities (p =.003; Table 5). Interestingly, reported turnover of paid staff is positively associated with turnover of volunteers (p =.001, Table 5).
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More than half (54.9%) of ombudsmen stated that the placement of their state LTCOP creates difficulties for them in terms of their ability to fulfill their mandate under the OAA (Survey Question 1). In some instances, constraints around organizational placement impede the efforts of ombudsmen to fulfill the requirements of legislative and administrative policy advocacy. When state ombudsman responses are examined by the organizational placement of their LTCOP, 62.2% of those within SUAs and 60% of those in other state agencies reported that the placement of their program creates difficulties for service provision, whereas only 22.2% in independent agencies reported difficulties caused by program placement.
Of the problems stemming from organizational placement of the program, lack of autonomy is mentioned most frequently (Survey Questions 3a and 5g). Close to one-third (29.7%) of state ombudsmen in SUAs reported that their program's placement limits their freedom to speak with legislators, the media, or both. In contrast, only 6.7% of state ombudsmen in nonprofit agencies, legal agencies, or non-SUA state agencies reported experiencing limitations on autonomy caused by the placement of their program. Also notable is the fact that of the ombudsmen reporting conflicts of interest caused by program placement (24.3%), all are located in SUAs. (For more discussion on organizational placement, see Estes, Zulman, Goldberg, & Ogawa, 2002.)
These findings suggest that being located in an SUA may hinder advocacy efforts and impede autonomy of the LTCOP. Some ombudsmen who are in SUAs and are therefore state employees reported that even though they are ostensibly free to speak to legislators and the media, the structure of their SUA imposes bureaucratic barriers (such as requiring that communication be preapproved).
Nevertheless, state ombudsmen also reported that SUAs may provide valuable assistance to their programs, including financial support, administrative and technical assistance, legal services, advocacy for the program, and the use of facilities and supplies (Survey Question 16). Being housed outside an SUA may diminish these types of support. Several state ombudsmen in programs located outside SUAs reported encountering their own difficulties caused by placement, including a lack of access to state amenities (such as travel resources and supplies), budget vulnerability caused by the lack of a protective umbrella agency, and limitations on autonomy by the umbrella nonprofit agency. In addition, fully one-third (34.2%) of state ombudsmen in programs within SUAs reported having no difficulties caused by their placement. A statistical analysis of program placement, resources, and effectiveness did not demonstrate any significant relationship between the organizational placement of LTCOPs and their funding or staffing levels or the self-ratings for effectiveness.
However, there are significant positive associations between state ombudsman responses to the questions of whether their program's placement allows for sufficient autonomy, and both (a) their freedom from excessive legislative or regulatory restrictions (p =.002), and (b) their ability to carry out federal mandates independently from other state agencies and parties (p <.001; Table 5). In addition, there is a significant and positive association between ombudsman reports of "sufficient program autonomy" and effective legislative and administrative policy advocacy (p =.038; Table 5), but no association with other self-rated effectiveness on statutorily mandated requirements (including complaint investigation, and community, family, and resident education).
Relationship With Other Agencies
Legal services provide essential support for ombudsmen. The majority of state ombudsmen rated the advice from their legal counsel as "very effective" (58.3%) or "somewhat effective" (27.1%; Survey Question 19a), but only two-thirds (66.7%) reported that they have sufficient legal services available (Survey Question 5p). State ombudsman responses indicate that effectiveness of legal counsel is positively associated with effectiveness of LTCOPs at the state level (p <.001) and effectiveness of work with nursing facilities (p =.006; Table 5).
The large majority (75.5%) of state ombudsmen reported that the political and social climate in their state is supportive of the mission of the ombudsman program. Ombudsman reports of a supportive political and social climate are significantly and positively associated with reports of sufficient program autonomy (p =.004) and their ability to carry out federal mandates independently from other state agencies and parties (p =.001; Table 5).
When asked if there are any barriers or impediments at the state or federal level that keep state ombudsmen from carrying out their jobs, 39.2% said barriers exist at the state level, 11.8% reported that barriers exist at the federal level, and 21.6% reported that barriers exist at both the state and federal level (Survey Question 40). Barriers at the state level include conflicts of interest with their umbrella agencies, a strong nursing home industry lobby, lack of cooperation with other agencies, lack of autonomy in advocacy efforts and in legislative and media contacts, resource and funding issues, hierarchical and bureaucratic structure of state agencies, state mandates that require broad coverage, and a conservative political climate. Barriers at the federal level include inadequate monitoring and enforcement of laws by the AoA, budgetary issues, and inadequate notification about survey scheduling.
According to 78% of state ombudsmen, the strong nursing home industry lobby in their state influences the effectiveness of their political advocacy efforts (Survey Question 41). When asked to explain, ombudsmen stated that the nursing home industry is very powerful as a result of large contributions to legislators' campaigns and FT lobbying efforts. In some states the industry has blocked the passage of nursing home staffing legislation. Some ombudsmen reported that they do not have the time, money, or autonomy to speak out and counter the actions of the nursing home industry.
Another factor influencing political advocacy efforts in the state that is reported by close to one-half (48%) of the state ombudsmen is relationship problems with either SUAs or the AAA (Survey Question 41). Strained relationships might be expected in cases of conflicts of interest and lack of autonomy for the state ombudsman program within the SUA. Some ombudsmen reported interference by SUAs and AAAs in both systemic advocacy efforts and at an individual case level. Other related problems include lack of support from AAAs for their local ombudsman program, lack of continuity caused by changes in the SUA director's position, lack of control or influence regarding contracts, and conflicts between the SUA and regional units. During the course of this study, one ombudsman resigned, citing unacceptably restrictive conditions imposed by the SUA that would limit the ombudsman's ability to act in the best interest of residents.
Over half (54%) of state ombudsmen reported that there are types of assistance they would like to receive from their SUA that they are not currently receiving, including more financial support and assistance in seeking additional funding, visibility and support for their mission, independence or support for the autonomy of the ombudsman program from the state agency, and legal support (Survey Questions 17 and 17b).
In terms of their program's relationship with citizen's advocacy groups (CAGs), 35.4% of state ombudsmen reported that their relationship with CAGs in their state is "very effective" or "somewhat effective." However, more state LTCOPs (47.9%) reported "somewhat effective" CAG relationships (Survey Question 42). Effective relationships with CAGs are significantly and positively associated with effectiveness of legislative and administrative policy advocacy (p <.001; Table 5). Factors that contribute to an effective relationship with CAGs include regular communication, common goals, attendance at each other's meetings, the ability for CAGs to advocate when ombudsmen cannot speak out, and working together on legislative agendas. State ombudsmen attribute ineffective relationships with CAGs to different priorities and focus, the need to build awareness among CAGs that ombudsmen are also advocates for LTC residents, and turnover within CAGs (Survey Question 42a).
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As noted in the section on Findings, a large majority of state ombudsmen report that their budget over the past 3 years was inadequate to fund their meeting federal requirements (approximately two-thirds of LTCOPs) and state requirements (almost three-fourths of LTCOPs; Survey Question 29). One consequence of inadequate funding is that ombudsmen are prevented from carrying out unannounced friendly visits (IoM et al., 1995). These routine visits are crucial in order for ombudsmen to be accessible for residents who cannot place telephone calls to the LTCOP. The relationship between funding and the number of volunteers is also relevant because they typically perform an important function in such visits. Inadequate funding is likely to necessitate LTCOPs to limit their focus on more immediate concerns rather than pursuing policy or systems change that may be producing the residents' complaints. Although the majority of state ombudsmen rank their programs as "very effective" in resolving complaints, inadequate resources may well account for their less positive self-ratings of effectiveness in implementing other federal and state mandates (such as resident, family, and community education, and systemic advocacy). Without sufficient LTCOP resources, their ability to influence systemic and long-term changes is likely to be severely limited. The potentially deleterious consequences for LTC quality will become an increasingly salient issue as the demographics of aging continue increasing the demand for LTC and the settings to accommodate it (including residential, board and care, and in home care). Quality of care issues remain paramount in all of these settings (Harrington, Woolhandler, Mullan, Carrillo, & Himmelstein, 2002). LTCOPs cannot reasonably be expected to increase their effectiveness (or even hold their own) if there are little or no increases in financial support for the program as demand increases.
Staffing of the ombudsman program (both paid and volunteer) is a crucial element in enabling ombudsmen to carry out their mandated responsibilities and how they rate their own effectiveness. Staffing shortages have been somewhat alleviated in several states by strengthening the presence of volunteers. As indicated by the study findings reported here and those of others, volunteers may make important contributions to the effectiveness of state and local ombudsman programs (Cherry, 1993; IoM et al., 1995; Keith, 2000b; Nelson et al., 1995; Netting, Huber, Paton, et al., 1995).
The study confirms the literature on the relevance of the autonomy and independence of the LTCOP for the perceived effectiveness of the program (Huber, Borders, Badrak, et al., 2001; Huber et al., 1996; IoM et al., 1995). In the telephone survey, organizational autonomy of the ombudsman program was a major issue associated with the program effectiveness, particularly in the area of systemic (legislative and administrative policy) advocacy. Problems with organizational placement include impaired ability to objectively and independently investigate and resolve complaints, and lack of autonomy to speak to legislators and the media. A supportive or nonsupportive political and social environment is also related to autonomy of the LTCOP.
Concerns about program independence and autonomy were raised repeatedly by state ombudsmen, indicating that placement within a state agency may be associated with several difficulties related to program performance. Being located in an SUA may hinder advocacy efforts by impeding autonomy. A primary issue is the potential for conflicts of interest. The 1995 IoM report recommended that by fiscal year 1998 no ombudsman program should be located in an entity of government or agency outside the government whose head is responsible for licensing and certification, provision of LTC services, adult protective services, and Medicaid eligibility determination (IoM et al., 1995). According to state ombudsmen, however, a number of programs remain in an umbrella agency with their state's licensing and certification agency, adult protective services, or the programs administering Medicaid. Although more than one-half of LTCOPs reported "difficulties" for their service provision because of their organizational placement (Survey Question 3), placement within a SUA does not necessarily have to be a problem in itself, if the potential conflicts of interest and limitations on autonomy are resolved to the satisfaction of all parties.
The interorganizational relationships of the state LTCOPs with others also are important in understanding self-rated effectiveness. State ombudsmen reported that uncooperative relationships with regulatory agencies negatively affect their political advocacy efforts, whereas interagency coordination and collaboration (with SUAs, local LTCOPs, AAAs, provider agencies, and citizen's advocacy groups) enhance advocacy efforts. Having no enforcement authority, state LTCOPs often find their observations ignored by regulators. Freeman (2000) posited that discourse between nursing home regulators and advocates can enhance reaching goals, including quality of care for residents of LTC facilities. A majority of state ombudsmen reported needing additional financial support and assistance to increase visibility and support for their mission, acquire stronger legal support, and obtain autonomy from the state agency.
In terms of oversight of the LTCOPs, study findings are consistent with the 1995 IoM report's statement that the AoA should play a stronger role in monitoring state LTCOPs and take action when states are not in compliance with the OAA. The IoM report recommends the development and application of sanctions when states are out of compliance on significant performance measures (IoM et al., 1995). Findings of the present study suggest the need for the AoA to monitor SUAs and LTCOPs on a continuing basis and to ensure that the LTCOP receives adequate funding and organizational independence to fulfill its statutorily mandated requirements in states across the United States.
Ombudsmen report that their relationship with CAGs can greatly increase their effectiveness, particularly in their legislative and administrative policy activity. Several ombudsmen, however, report that their relationship with certain CAGs has become antagonistic largely because of misunderstandings about the fact that, under the law, LTCOPs have no regulatory role in LTC facilities. It is important for AoA and LTCOPs to clarify the ombudsman role as one of mediation and conflict resolution, but not one in which the ombudsman has either the designated responsibility or authority to take regulatory action against facilities. Other misunderstandings occasionally arise because CAGs perceive that ombudsmen are not doing all they can to advocate for the rights of residents, when in fact they are limited or prohibited from speaking out as a result of the organizational placement and structure of their program (i.e., the autonomy issue).
Results from this study target three types of factors associated with the perceived effectiveness of the state LTCOP: adequate resources, organizational placement-autonomy, and relationship with other agencies. Future research is needed in the continuing development of outcomes measures begun by NASUA (2000) and the National Long Term Care Ombudsman Resource Center and the empirical work on compliance assessment started by Huber, Borders, Badrak, and colleagues (2001). Such standardized measures are needed for both the state and local ombudsman levels in order to better understand the factors that shape LTCOP effectiveness (both self-rated and other measures) and to advance research knowledge and practice to improve the quality of long-term care.
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1 Institute for Health & Aging at the University of California, San Francisco.
Decision Editor: Laurence G. Branch, PhD
Received for publication August 8, 2001. Accepted for publication July 29, 2002.
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3058g (Public Law 106-501).,.
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