Introduction to the Ombudsman Program

What is an Ombudsman
Program Description
History of Nursing Home Care
History of the Ombusdman Program
Program Structure
Title III Older Americans Act
Philosophy of Long-Term Care Ombudsman
Mission Statement and Goals

What is an Ombudsman?
The word ombudsman (om-budz-man) is of Swedish origin, and means one who speaks on behalf of another. The Missouri Long-Term Care (LTC) Ombudsman Program is comprised of individuals whose main responsibility is to help residents in long-term care facilities maintain or improve their quality of life by helping ensure their rights are not violated.

Ombudsman Roles
The ombudsman has many different roles that may be applicable:

1. Facilitator : Helps people formulate or simplify problems and complaints.
2. Educator: Provides learning materials and educational brochures to facility staff, families, residents and the community at large, thus encouraging self-help and problem solving.
3. Broker: Makes referrals and monitors the referral to see that the problem is solved.
4. Intermediary: Promotes communication among those involved in a problem concerning long-term care.
5. Collaborator: Works with residents and staff toward mutually beneficial solutions.
6. Mediator: Brings together all pertinent individuals to arrive at an agreement or a compromise.
7. Advocate: Act on behalf of someone else.
8. Investigator: Gathers pertinent information from many sources. It is particularly important to evaluate the facts impartially.
9. Problem solvers: Brings about resolutions to problems or complaints concerning various aspects of long-term care.
10. Negotiator: Arranges for differing parties to discuss their issues and provides an objective third party viewpoint.

Ombudsman Program Description
Missouri's ombudsman program consists of ombudsman/volunteers serving residents of nursing homes and residential care facilities to provide support and assistance with any problems or complaints. Individual ombudsman volunteers are recruited by Area Agencies on Aging (AAAs) or their service providers. Following screening and training, the ombudsman is assigned to a facility that has agreed to participate in the program. The ombudsman receives orientation to the facility and its procedures, prior to making regular contact with the residents.

Having an ombudsman assigned to a particular facility provides the most accessible means of complaint resolution. Missouri's Long-Term Care Facility Regulations include resident access to the services of an ombudsman, 19 CSR 30-88.010-2(18).

The program seeks to diminish the sense of isolation experienced by residents, especially those without family. The ombudsman can assist the resident in achieving a sense of self determination. Ombudsmen strive to reinforce the importance of resident rights. While residents are provided information regarding their rights upon admission, the ombudsman is there as the resident adjusts to the facility to reiterate those rights and offer assistance in exercising those rights.

Even though facilities are required to have a grievance procedure, residents may be hesitant to voice concerns/complaints to a facility staff person for any number of reasons, i.e. fear of retaliation if the complaint was directed at a staff member. However, since ombudsmen are often members of the community and not tied to the facility, they are perceived as more objective/receptive to complaints. Residents may even initially hesitate to register a complaint with an ombudsman; however, one of the advantages of the volunteer program model is that it enables the ombudsman to become a trusted friend over a period of time. By regular contact with residents the ombudsman becomes a confidant. The resident is assured of confidentiality, and the ombudsman will not pursue a complaint without the resident's permission. Once the Ombudsman gains the resident's confidence, she may be able to provide encouragement and information to allow the resident to handle the complaint her/himself or the ombudsman may be asked to speak on behalf of the resident to administration and/or to other parties regarding any problems. The ombudsman provides prompt feedback to the resident regarding efforts to resolve complaints.

Ombudsman volunteers are special. They are asked to make a significant commitment to the program, not only in terms of replacement and ongoing inservice training but through weekly contact with residents, reporting and travel.

** It is important to note that there may be times when permission is not given or it is withheld and yet some action ought to be taken for the safety and welfare of the resident. There will be further discussion on this subject later in this manual. However, if an ombudsman is ever in doubt as to how to handle a specific situation he/she should make contact with the regional ombudsman coordinator.

History of Nursing Home Care
Providing health care can be traced back through the centuries, even several centuries B.C. In early A.D. the Roman Empire authorized the Christians to build facilities to get the sick, poor, and aged off the streets. As the health care system advanced in the 1800s physicians started the practice of visiting patients in health care facilities. But these facilities still were crude answers for caring for the sick and aged. In America, the facilities for meeting the needs of infirm elderly people who were poor became known as the "poor farm" or the "county home."

The nursing home industry was a by-product of the 1936 Social Security Act. This Act prohibited Old Age Assistance (OAA) dollars from going directly to residents in public institutions. The need for an alternative spurred the growth of private and non-private institutions and homes. The 1950 amendments to the Social Security Act, extended OAA into the public medical institutions. This escalated the transition of people from public institutions to the private/not-for-profit institutions.

The creation of Medicare and Medicaid in 1965 became the most important factors in today's society for the development of long-term care facilities. Medicare, a federal insurance program for persons over 65, will pay for a skilled nursing facility on a limited basis. Medicaid, medical assistance for poor individuals over 65, the blind, the disabled, and members of families with dependent children, is a federal and state financed program. These two programs account for approximately one-half of the payments made to nursing facilities (Medicare, 2%; Medicaid, 48%).

History of the Ombudsman Program
The long-term care industry grew fast during the 1960's with little regulation. Because of well-publicized reports of abuse, neglect and substandard conditions in nursing homes, several congressional committees were convened to hear testimony and propose regulations for the nursing home industry. In 1971, President Nixon directed the Department of Health, Education and Welfare to establish the office of Nursing Home Affairs. This agency would coordinate the efforts of the other department agencies to increase the standards nationwide in nursing homes. In 1972, the Long-Term Care Ombudsman Program was initiated as a result of the 1971 White House Conference on Aging. Its purpose was to help states establish an investigative unit which would respond to complaints in long-term care facilities.

The Administration on Aging (AoA), located in the United States Department of Health and Human Services, is the federal agency charged with responsibility for coordinating programs that benefit the elderly. AoA allocates the funds authorized under the Older Americans Act. AoA is responsible for enforcing program priorities and allocation standards established by Congress.

In 1975, AoA made a small amount of funds available to states to develop the abilities of the Area Agencies on Aging to implement ombudsman activities. Missouri took advantage of these grants to establish the long-term care ombudsman program.

In 1978, the amendments to the Older Americans Act elevated the Nursing Home Ombudsman Program to a statutory level. The statute and subsequent regulations required all state agencies on aging to establish an ombudsman program. The 1981 reauthorization of the Older Americans Act resulted in a further expansion of ombudsman duties. In addition to nursing homes, personal care homes were included in the ombudsman realm of responsibilities. The program name was changed to Long-Term Care Ombudsman to reflect these added responsibilities. The 1987 Amendments to the Older American's Act strengthened significantly the program's ability to advocate on behalf of residents in long term care facilities.

Missouri Ombudsman Program Structure
The Missouri Division of Senior Services and Regulation, located in the Missouri Department of Health and Senior Services, is the hub for state advocacy services on behalf of the elderly.

The DHSS houses the Missouri Long-Term Care Ombudsman Program. The office of the State Long-Term Care Ombudsman (LTCO) is the highest reporting authority for the state and local ombudsman programs. The state Long-Term Care Ombudsman coordinates the activities between the DHSS, The Regional Ombudsmen and the local ombudsmen volunteers. The state Long-Term Care Ombudsman works with advocacy groups, associations, and other interested agencies for the purpose of promoting the ombudsman program.

Missouri's ten Area Agencies on Aging administer the program on the local level by designating someone as the regional ombudsman coordinator. This coordinator may be an Area Agency on Aging staff person or may be a person who contracts with the area agency. Responsibilities of the coordinator include recruitment, training and supervision of volunteers.

The State Long Term Care Ombudsman is the contact for all ombudsman activities in the state. Changes on policies, regulations, reporting requirements, or information updates are primarily via the State Ombudsman. The Regional Ombudsman Coordinators attend quarterly meetings hosted by the State Ombudsman. This meeting is used to exchange information and provide in-service training. The Ombudsman at the local level is always encouraged to solve problems at their own level. If the situation warrants it, the Regional Ombudsman Coordinator can be called upon to assist. The Regional Ombudsman Coordinator is able to call upon the State Ombudsman to assist in the situation when specific technical information is needed, the problem is a system-wide problem or added authority needs to be lent to the situation. In the ombudsman program calling in "THE STATE" means calling upon the State Ombudsman office to provide assistance.

When facility staff hear the term "THE STATE," they most likely think of the Section for Long Term Care Regulation (SLTCR) regional office staff (often called the state inspector's.) These are Division of SLTCR staff who are charged with the responsibility of conducting surveys twice a year in all facilities. It is through these surveys that facilities are notified of problems and/or areas of concern which need to be corrected in order for them to remain in compliance with Missouri state statues and regulations. SLTCR has seven offices located through out the state. Contact with regional staff may be formal or informal. Meetings of various nature, i.e., industry, training, quarterly in-service, etc., provide group contact and an opportunity to coordinate/promote program activities. (Please note that confidential information is never exchanged at any of these meetings.)

The Regional Ombudsman Coordinator interacts with the SLTCR staff on a regular basis. Prior to entering a facility for a survey, the Section for Long Term Care Regulation Regional Manager will consult with the Regional Ombudsman Coordinator about the types of complaints that ombudsmen are reporting. No confidential information is ever shared; however, the reports from the ombudsman in the facility can be very valuable in steering the inspector to situations that may need to be addressed.

The Regional Ombudsman Coordinators also have a contact with the Division of Senior Services toll-free hotline. Volunteers are not to call the hotline. The hotline is primarily for reporting resident abuse or neglect or exploitation of resources. The Regional Ombudsman Coordinators are kept informed as to the information needed to report such incidents.

Title III Older Americans Act

This chart shows the relationship of agencies responsible for implementing programs for the elderly, such as the Ombudsman program as outlined in the Older Americans Act.

Philosophy of the Long-Term Care Ombudsman

Volunteer Model
The adoption of the volunteer service model stems primarily from the belief that the extent of community presence in a long-term care facility has a direct, positive correlation with the quality of life in an institutional setting. Knowledge of a particular facility enables the volunteer to handle problems more effectively. An established relationship with the facility staff and residents facilitates resolution. Ombudsmen assume the role of confidant and as a result residents are more likely to express concerns that might not otherwise surface.

Ombudsmen provide a personalized approach to service delivery. Regular contact with residents builds trust, visibility and clarity of purpose, which in turn can encourage residents to solve issues on their own.

The focus of the ombudsman efforts is resident-initiated complaints. While complaints may be made on behalf of residents by other individuals, care is taken that such complaints accurately reflect the concerns of the resident. Complaints are received in the strictest of confidence.

Investigation/resolution is not attempted without the resident's permission unless the problem affects a number of residents and can be approached in a generic sense without breaching confidentiality. No problems is too big or too small for an ombudsman to deal with. Ombudsmen can often solve problems before they become serious.

Ombudsmen work within the system to make the system work for residents. By assuming the role of an independent, neutral mediator in seeking mutually satisfying solutions to grievances, Ombudsmen make a significant contribution to living conditions for residents.

A key in this program is the word "empower." To empower is to enable or permit some action. Ombudsmen should always look for ways to empower residents to help themselves. It would be ironic if this very system, set up to ensure that residents know their rights and maintain their dignity, became part of the problem. Mediating a situation is just as important a function as is being an advocate.

Statement of Overall Program Policy
It is important to understand the Ombudsman Program does not have enforcement powers of its own and is not a regulatory agency in any sense. Trust and confidence can be maintained only as long as residents, nursing home facilities, agencies and the public know the ombudsman has no vested interest in any given case. The ombudsman's only interest is ensuring long-term care residents are able to freely exercise their rights.

Missouri Ombudsman Program Mission Statement and Goals
The mission of Missouri's Long Term Care Ombudsman Program is: To improve the quality of life for residents of long term care facilities through advocacy and education. The goals of the program are :

• To provide ombudsman services to all residents of all long-term care facilities in Missouri, including Intermediate Care Facilities for the Mentally Retarded and Veterans Administration Nursing Homes.
• To advocate for residents rights.
• To provide community education regarding long-term care facility issues.

This is the task set before each volunteer ombudsman. These goals will help to ensure and maintain the best quality life possible for all residents in long-term care facilities.

To achieve these goals ombudsmen should:

• Make sure all residents are informed of their rights as established by law.
• Strive to empower residents and/or help to resolve all complaints at the facility level through the involvement of all concerned parties.
• Work with the Regional Ombudsman Coordinator to provide suggestions for relaying non-confidential information to the community on residents needs and concerns.

Quality of Life
Quality of Life refers to elements which make life worth living. The components by which quality of life would be measured are not all quantifiable. Needs vary from individual to individual. However, the licensing and certification regulations provide some guides to measuring quality of life. The mediation process will help clarify issues and allow the ombudsman to assist in correcting situations which diminish rather than enhance quality of life.