Performance Improvement 1996. Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act



This report describes a 1-year project to evaluate long-term care ombudsman programs, which investigate complaints made by or on behalf of residents of nursing facilities and board and care (B&C) homes. The report sets forth recommendations related to program availability, adequacy, and effectiveness for residents of long-term care facilities; compliance with Federal program mandates; adequacy of current Federal, State, and local program resources; and the feasibility of extending ombudsman services to older persons who do not reside in long-term care facilities. Overall, the report strongly supports long-term care ombudsman programs and their continuation and urges a stronger Federal Government role in providing program leadership, guidelines, and oversight.


The purpose of this study is to assess the effectiveness of State-based long-term care ombudsman programs in providing advocacy for the health, safety, welfare, and rights of those who reside in long-term care facilities and B&C homes. Under contract with the Administration on Aging (AoA), the Institute of Medicine convened a multidisciplinary expert committee to evaluate long-term care ombudsman programs and to consider the potential impact of these programs on other target populations, in other settings, and in other circumstances. This evaluation project was mandated by the 1992 amendments to the Older Americans Act.


Long-term care ombudsman programs were created more than two decades ago as a response to serious concerns about the quality of nursing home care. Currently operating in all 50 States, the District of Columbia, and Puerto Rico, these programs are funded from a combination of Federal, State, and local sources.

Over the years, the role of the ombudsman has evolved to include both individual and systemic advocacy. Individual advocacy activities are designed to ensure that ombudsman services are accessible to all residents, systematically receive and respond to resident concerns about their long-term care services, and work cooperatively with a variety of agencies to resolve problems.

Systemic advocacy activities include evaluation of laws and regulations related to long-term care services for older adults, education of the public and facility staff, dissemination of data about the ombudsman programs, and promotion of the development of citizen organizations and resident and family councils. Both roles are important, but the ombudsman programs primarily identify, investigate, and resolve individual resident complaints.


The committee developed a formative evaluation strategy to identify program issues, strengths, and weaknesses. Both qualitative and quantitative data were collected and analyzed using a triangulated approach and a form of recta-analysis, which incorporates multiple dimensions of program effectiveness, individual interpretations, and expert opinions. A technical panel was convened twice and consulted as needed.

Although there is no national database or source of standardized information, numerous sources of primary and secondary data were used. Two- to three-day site visits were made to programs in California, Colorado, Florida, Massachusetts, Minnesota, and Virginia. Seven papers were commissioned, and a thorough literature review was undertaken.

Structured, systematic contacts were made with directors of State units on aging, State and local long-term care ombudsman program offices, long-term care physicians, and consumer advocacy groups. A 1-day invitational symposium, a public hearing, and two "open-mike" sessions were conducted. Discussions were also initiated with four national associations of long-term care facility providers.


The report underscored the vital public purpose served by long-term care ombudsman programs and endorsed the continuation of their mandate, offering several examples of ways in which the programs have provided valuable assistance to individuals and improved the service system. The committee could not offer a definitive assessment of program effectiveness, however, because of the lack of uniform process and outcome data for all States and the lack of theoretical consensus regarding the use of appropriate effectiveness measures. Instead, the committee reported selected findings and encouraged the development of a process to facilitate uniform process and outcome evaluation in the future.

In some areas, the committee found that meaningful access to ombudsman services does not exist for all eligible nursing facility residents because of infrequent site visitation and insufficient information outreach efforts. In general, complaints receive a timely response. Program implementation in B&C homes is much more limited than in nursing facilities.

Considerable variation among States in the extent of program implementation in nursing facilities is noted. At the systemic level, the committee observed that too many States operate fragmented programs that only respond to individual complaints rather than functioning as unified, integrated programs. Many States lack access to adequate, independent legal advice and backup for ombudsmen and for residents who need assistance in courts and regulatory hearings.

The committee also found that current resources are inadequate to support full implementation of program mandates. It recommends that Federal funds for the program be increased from the current $25 million to $39.5 million by fiscal 1998. This increase would provide funding to achieve the committee's recommended staffing level of one ombudsman full-time equivalent for every 2,000 long-term care beds. (The current ratio is one to every 2,700 beds.) The committee also recommended that resources be apportioned among the States on the basis of the number of beds rather than the number of persons aged 60 years and over, as is currently done.

The committee recommended a strengthened leadership and oversight role for the Federal Government, including the implementation of an objective compliance review method for States. An improved data system is needed that includes information about program awareness, as well as the extent of complaint resolution, the extent of ombudsman input into systemic improvement activities, and the extent of ombudsman impact on the overall system of long-term care and services.

Concern was expressed that expanding the program to cover persons who do not reside in long-term care facilities may hinder the ability of ombudsmen to serve their current constituencies in nursing facilities and B&C homes. The committee recommended that expansion capacity, target populations, organizational placement, staffing needs, and funding receive careful consideration before any expansion efforts to non-institutional care settings are undertaken. The importance of developing and supporting research and demonstration projects in this arena was also noted, with attention to demographic and health care system trends affecting the long-term care system.

The report indicates that it was premature to evaluate the impact on residents of B&C homes because long-term care ombudsman programs have been only partially implemented there.

Use of Results

The development of a nationwide database of key structure, process, and outcome program measures is proposed. This study can be used by local and State ombudsman programs to assess their own strengths and weaknesses and to improve their performance. The Federal Government can consider recommendations to strengthen its role as leader, researcher, funder, guide, and monitor. Findings can also be useful to agencies that consider developing, adapting, or expanding ombudsman programs for other populations and services. It is also suggested that program expansion be delayed until existing mandates are fully implemented.

Agency sponsor:

Office of Program Operations and Development

Federal contact:

Nancy Wartow
PIC ID: 5819
NTIS Accession Number: PB95-174223

Performer organization:

National Academy of Sciences, Institute of Medicine, Washington, DC