Institute of Medicine Report

Real People, Real Problems:
An Evaluation of the Long-Term Care Ombudsman Programs
of the Older Americans Act by the Institute of Medicine
SUMMARY SHEET
Developed by Hollis Turnham, Esquire

In 1995, the Institute of Medicine (IoM) published the first and only national evaluation of any program created by the federal Older Americans Act (OAA). At the urging of long term care Ombudsmen themselves, Congress asked the Administration on Aging (AoA) to complete an in depth assessment of the Long Term Care Ombudsman program (LTCOP) as part of their 1992 reauthorization of the OAA. was created in 1970 by the National Academy of Sciences to “advance and disseminate scientific knowledge to improve human health. The Institute provides objective, timely, authoritative information and advice concerning health and science policy to government, the corporate sector, the professions and the public.” To complete the Ombudsman evaluation, the IoM convened a distinguished committee Francisco, of 16 nurses, physicians, researchers, clinicians, attorneys, program administrators, and advocates all experienced or interested in long term care under the leadership of Carroll Estes, Ph.D., then Director of the Institute for Health and Aging at the University of California, San Francisco. A local and a state Ombudsman were also members of the study committee.

The final report examined four key issues related to the LTCOP:

• The degree of compliance with the federal program requirements including conflict of interest;
• The availability of, unmet need for, and effectiveness of the LTCOP;
• The adequacy of federal and other resources available to operate the program; and
• The need for and feasibility of providing Ombudsman services to elders using long term care services outside a facility.

By any measurement, the IoM report has had an enormous impact on not only the LTCOP but also on the national discussion of the information, education, and advocacy needs of health care consumers and the art and science of being an Ombudsman. The report both forecast and laid the foundation for LTCOP expansion, outcome measurements, reporting systems, and standards. The report has been used by national health advocacy organization to urge the creation of an Ombudsman for all health care consumers, (see Families USA article http://www.familiesusa.org/omron.htm), to justify federal legislation granting states funds to create a Health Care Consumer Assistance Office within each applying state. S.651, and to conduct supportive hearing proceedings: http://www.senate.gov/~labor/107hearings/mar2001/032801wt/032801wt.htm

Since the statutory base of the LTCOP was changed very little in the 2000 reauthorization, the IoM report remains a treasure chest of tools for the improvement of every LTCOP. Important information includes:

• Defining an “exemplary” LTCOP as one that “operates as a whole, unified, integrated, and cohesive program focused on serving the advocacy needs of LTC facility residents and others assigned and separately funded. In addition to serving today’s needs, the program is in the forefront of tomorrow’s issues. In order to resolve issues, the program engages in a broad-based discussion with all players and remains focused on resident interests.” (Table 5.6)
• Recommended LTCOP staffing ratios of 1 paid full-time equivalent (FTE) Ombudsman for every 2,000 licensed long term care beds within a state. Also, 20 to 40 volunteer Ombudsmen should be supported by 1 paid FTE Ombudsman. The IoM analysis and recommendations have been used to increase both state and federal funding of the Ombudsman program. (Pages 159-161, chapter 6)
• An in-depth discussion of the nature of conflicts of interest and markers of LTCOP independence and ability to remain “resident-centered” in their advocacy. This IoM analysis has motivated several states to relocate the state or local program offices to reduce the potential for real or perceived conflicts of interest. (See chapter 4)
• Calls for better data to document the work of LTCOP, to quantify the issues faced by residents, and to evaluate the impact of LTCOP services. The AoA and many states have revamped reporting requirements and data analysis to address the shortcomings noted by the IoM and to improve the program’s effectiveness. The AoA and many LTCOPs have distributed program data more widely to explain the needs of long term care facility residents. (Page 155-159, Table 5.1)
• Detailed analysis of the role adequate legal counsel can and should play in the program’s essential infrastructure. (Pages 93-96, 117-119)
• A comprehensive guide for programs to evaluate their own effectiveness and for future researchers to evaluate LTCOPs. The guide also includes “unacceptable” program practices that, in the Committee’s opinion, “do not conform with the mission of the program as envisioned by Congress.” (Tables 5.2 through 5.9) Several states and local Ombudsman programs have used this comprehensive guide to evaluate their compliance with the OAA’s requirements, to develop quality improvement plans, and to monitor program activities.

The full IoM report on Long Term Care Ombudsman Programs is available online at http://www.nap.edu/books/NI000028/html/. The Executive Summary of the report is also available from the same address. Both documents are in a searchable format so that if you want to find every reference to “volunteers” or “legal counsel” you can quickly get to those references. Unfortunately, a small number of copies of the full report were published in 1995; the full report book is long out of print.

In 2001, the chair of the IoM Ombudsman study panel,Dr. Carroll Estes of the University of California at San Francisco is conducting a follow-up study to the 1995 work. Funded by the Kaiser Family Foundation, she is examining the role and responsibilities of today’s Ombudsman programs and the positive and negative factors that contribute their effectiveness.

Just as Dr. Fleming believed that the LTCOP was created to help resolve the real problems of real people, the IoM evaluation of LTCOPs can help real Ombudsmen solve their own real problems in creating “whole, unified, integrated, and cohesive program focused on serving the advocacy needs of LTC facility residents.”