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Effectiveness of the State Long-Term Care Ombudsman Programs
Pages 129-184

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From page 129...
... Nelson, Of lice of the LTC Ombudsman, Oregon, personal communication, February 1994~. Nevertheless, the committee regarded it as imperative to attempt some formal evaluation in line with its official charge.
From page 130...
... Hence, they provide the basis for the formative nature of this evaluation and the nature of the committee's recommendations. The chapter ends with a series of recommendations intended to improve the capacity of the national and the state programs.
From page 131...
... Consequently, the specific purpose of the IOM review is to investigate some evidence regarding the effectiveness or ineffectiveness of the ombudsman program while it is still evolving, in order to facilitate decision making and improve program management. Thus, in addition to attempting to shed some light on the larger question of what difference the program makes, the committee's primary goal has been to encourage positive program changes and improvements that are needed in view of evidence available to date in the lives of individual residents of LTC facilities and at the system level.
From page 132...
... Although the committee did not combine and reanalyze data, the committee applied a meta-analytic approach in the sense that it examined, compared, and analyzed previous qualitative and quantitative research findings on program effectiveness from multiple data sources. Given the variability and lack of comparability in available 50-state data, the committee concluded that a comprehensive statistical approach to obtaining
From page 133...
... ; and Toward Quality Long-Term Care Ombudsman Programs, from the National Center for State LTC Ombudsman Resources (1991~.
From page 134...
... . Under this assumption, the variation inherent in ombudsman programs at the state and local level can be expected to result in differential influences on the quality of services provided to residents of LTC facilities.
From page 135...
... In developing this framework, the committee referred to OAA provisions related to duties and responsibilities of both the state and local ombudsman programs. The necessary infrastructural and functional elements of an effective ombudsman program in every state are described in the following categories:
From page 136...
... However, the committee finds these practices unacceptable and antithetical to the mission of program, and it takes the position that AoA, SUAs, ombudsmen, and all advocates for LTC facility residents ought to work aggressively to eliminate them.
From page 137...
... This includes the state ombudsman, state ombudsman staff, regional or local paid ombudsman staff, and volunteers. All representatives of any Office of the State LTC Ombudsman are subject to a designation process before they can conduct any ombudsman functions.
From page 138...
... Second, the committee recognizes that the various ombudsman programs, understandably, differ In infrastructure and function, and that no one program will be exemplary in all elements. In constructing this set of practices, therefore, the committee hopes to challenge all programs to reach new levels of effectiveness and service to the nation's residents of LTC facilities.
From page 139...
... in describing the contribution ofthe ombudsman program in partnership with others in improving nursing facility quality. EFFECTIVENESS OF THE OMBUDSMAN PROGRAM: THE DATA Most analyses of the efficacy of the LTC ombudsman programs occurred in single-state studies (Cherry, 1991, 1993; Nelson, in press; Nelson et al., in progress)
From page 140...
... - Increased community awareness · Facility closure and receivership, when needed · Positive interaction with facility staff · Establishment of organizational, interorganizational, and associational mechanisms to identify, inform, and resolve problems
From page 141...
... Although statistical analysis was not part of the inspection, the GIG study (199 la,b,c) showed that, among state programs that use volunteers, those with more volunteers paid more visits to LTC facilities and filed and resolved more complaints.
From page 142...
... of state ombudsmen would have preferred either weekly or biweekly visits to all LTC facilities, but they cited the lack of staff resources as the major deterrent to more frequent visitation patterns. More Finding, it was implied, would have resulted in more professional staff who could have visited or trained volunteers to visit.
From page 143...
... Neither Huber nor other researchers have found any conclusive evidence to support linking effectiveness of the ombudsmen program with the sources that initially file complaints nor with the types of complaints that are reported, investigated, or resolved. Through analysis of information provided by state ombudsmen in their annual reports and responses to the canvass, Chaitovitz concludes that ombudsmen in local programs serving residents of nursing facilities function as expected: they advocate for residents in nursing facilities, report and resolve complaints, mediate disputes, and educate residents and staff of nursing facilities.
From page 144...
... report on a survey of administrators, directors of nursing, and social workers in randomly selected nursing facilities in substate regions with the "most active" regional ombudsman programs (as designated by the state ombudsman) Additionally, the investigators' findings reflect input from focus group discussions with providers of both not-for-profit and for-profit nursing facilities, as well as state and national leaders in the industry.
From page 145...
... : . The state ombudsman programs provide info~.~ation about trends and issues that affect the well-being of LTC residents (80 percent)
From page 146...
... His work on role conflict is particularly relevant to the use of volunteers in the ombudsman programs. He concludes that ombudsman program managers must provide clear role definitions for volunteers and provide adequate training and support to help eliminate incorrect or vague role expectations.
From page 147...
... (In Chapter 6 the committee discusses paid staffing levels in the context of performance and adequacy of resources.) Paid staff to volunteer ratios differ widely across the ombudsman programs (see Table 2.3 in Chapter 2~.
From page 148...
... keep the ombudsman programs in relative ignorance of each other and inhibit them from sharing common problems and, more importantly, solutions that have worked in venous environments and settings.5 Help in developing information systems was requested by 40 percent of state ombudsman programs (Chaitovitz, 1994b)
From page 149...
... In any case, the state ombudsman has no direct authority over AAAs. If the AAA accepts the local ombudsman program, and then adds local funds, the AAA is likely to resent program direction initiating from the state ombudsman.
From page 150...
... was yet another staffing issue of concern to local ombudsman programs. Local ombudsmen noted that the turnover rate is also high among paid staff in local programs, and they attributed this to low pay scales, role misunderstandings, and frustrations over the lack of authority to make changes.
From page 151...
... To a large extent, these problems appear to be attributed to the ways in which state programs contract out for these local ombudsman programs, if they have them. Lines of accountability, from state ombudsman programs to local programs, and from local ombudsman programs back to state programs, are unclear if contracting occurs through third parties such as AAAs that in turn subcontract the ombudsman programs to entities further removed from the front line of accountability.
From page 152...
... . CONCLUSIONS AND RECOMMENDATIONS Continuance of the Ombudsman Program In this chapter the committee has attempted to assess the effectiveness of the state LTC ombudsman program from several perspectives.
From page 153...
... At the direct request of residents, their families, LTC facility staff, and others, individual resident advocacy services of staff and volunteer ombudsmen uniquely contribute to the well-being of LTC residents, complementing but not duplicating the contributions of regulatory agencies, families, community-based entities, and providers. Examples of effective services range from solving such everyday problems as the bath schedule of individual residents to resolving serious issues such as evictions and involuntary transfers.
From page 154...
... The committee observed such barriers as absence of local ombudsman programs from some areas of states, little or no individual resident advocacy services for B&C residents, and exclusive reliance on one centralized toll-free telephone line for an entire state with little or no opportunity for face-to-face advocacy services by ombudsmen on behalf of residents. In many states, the program attempts to operate in a structural environment that expressly prohibits or does not foster its ability to carry out all federally mandated functions.
From page 155...
... Thus: 5.2. The committee recommends that the Administration on Aging build upon the committee's proposed set of exemplary, essential, and unacceptable practices to develop and implement an objective method to assess compliance of state long-term care ombudsman programs.
From page 156...
... be based on a manageable number of uniform and reliable data items—each of which has precisely specified, field-tested definitions; · be derived from annual statistical reports submitted by state longterm care ombudsman offices that provide information in terms of the data items in the previous point; . include a clear indication of status of complaint resolution from a consumer perspective; · be used to provide feedback to state and local ombudsman programs; .
From page 157...
... Thus, all items intended for a formal data collection instn~ment should be carefully examined and included only if they have demonstrated utility for AoA or state or local ombudsman programs (or, ideally, both)
From page 158...
... with such outcomes as changes in LTC facility practices that show more respect for residents' rights or changes in state or federal laws that provide legislative backing for residents' rights. Just as research is being conducted to assess linkages between process, structure, and outcomes in various aspects of our health care system, so too the need exists for such research relative to the LTC ombudsman program.
From page 159...
... with such outcomes as changes in LTC facility practices that show more respect for residents' rights or changes in state or federal laws that provide legislative backing for residents' rights. Just as research is being conducted to assess linkages between process, structure, and outcomes in various aspects of our health care system, so too the need exists for such research relative to the LTC ombudsman program.
From page 160...
... It strongly encourages state LTC ombudsman programs to maintain paid staff-tovolunteer ratios at levels that are far more robust than the 1:40 level.
From page 161...
... Significant among these are inadequate funding, resulting staff shortages, low salary levels for paid staff, structural conflicts of interest that limit the ability to act, and uneven implementation within and across states. The committee developed a detailed set of ideal practice standards to guide AoA and the ombudsman programs toward more effective basic program implementation and practice.
From page 162...
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