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Annotated Bibliography:

The Role and Impact of the
Long-Term Care Ombudsman

As the number of older citizens increases, the population of nursing and assisted living facilities also increases. Older individuals living in institutional care environments are vulnerable to many types of abuse and neglect.

The Older Americans Act authorizes the Long-Term Care Ombudsman to play a significant role in addressing the mistreatment of residents, whether it involves a violation of a resident's rights, a deficiency in care, an administrative problem, or an issue concerning quality of life. He or she may interface with many people in addressing the complaint, including the resident, the resident's family, the staff and administrators of the facility, and possibly other agencies such as adult protective services and law enforcement.

As noted at the end of this bibliography, many resources on the Ombudsman Program are available from the National Center for Long-Term Care Ombudsman Programs. The following references highlight many aspects and challenges of the role of the Ombudsman as an advocate for older residents in long-term care. Most of those listed are from research literature and may be obtained through your local university and community libraries or interlibrary loan services. Some must be ordered directly through the publisher or production company.

When available, contact and pricing information is included with the abstract. Increasingly, many resources are available online, and the Web addresses are also included.* If you have difficulty obtaining any of these materials, please contact the CANE office for assistance at [email protected] or 302-831-3525.

*Note: Web addresses may change without notice. If an address provided is no longer accurate, we recommend using a generic search engine, such as Google, to find a current link. If you cannot locate the online publication, contact the CANE offices for assistance.

To review other CANE bibliographies, click here >>.

The National Center on Elder Abuse (NCEA) serves as a national resource for elder rights advocates, law enforcement and legal professionals, public policy leaders, researchers, and citizens. It is the mission of NCEA to promote understanding, knowledge sharing, and action on elder abuse, neglect, and exploitation.

The NCEA is administered under the auspices of the National Association of State Units on Aging.

NCEA Partners
        National Association of State Units on Aging (NASUA), Lead Partner
        American Bar Association (ABA) Commission on Law and Aging
        Clearinghouse on Abuse and Neglect of the Elderly (CANE) at the University of Delaware
        National Adult Protective Services Association (NAPSA)
        National Committee for the Prevention of Elder Abuse (NCPEA)<

This publication was made possible through the support provided by the National Center on Elder Abuse. Major funding for the National Center on Elder Abuse comes from the U.S. Administration on Aging, Department of Health and Human Services.
Grant No. 90-AM-2792.

Opinions or points of view expressed do not necessarily reflect the official position or policies of the U.S. Administration on Aging.


1. P5660-12
Estes, C. et al.
State Long-term Care Ombudsman Programs: Factors Associated with Perceived Effectiveness
The Gerontologist; Vol. 44 (1), 104-115; 2004.
Journal article (research)
This article reports upon a nationwide survey of factors associated with perceived effectiveness of state Long-term Care Ombudsman Programs (LTCOPs). Telephone interviews were conducted with representatives of LTCOPs from each state, Washington, D.C., and Puerto Rico. Overall, LTCOPs perceived their programs as effective, with nearly one-third reporting their program was very effective, and two-thirds indicating their program was somewhat effective. Three factors appear positively associated with perceived effectiveness: adequate resources, program autonomy, and relationship with other agencies. Detailed discussion is provided regarding organizational placement and its subsequent impact upon the program's level of autonomy, as 54.9 percent of the respondents felt that their location limited their autonomy and contributed to conflicts of interest. Findings suggest that being located in a State Unit on Aging (SUA) may hinder the Ombudsman's effectiveness in resolving complaints; however, such location was also reported to be beneficial in terms of practical support. In addition to the interviews, researchers used data from the Administration on Aging's National Ombudsman Reporting System (NORS, 1999).

2. P5659-5
Nelson, H. et al.
Factors Important to Success in the Volunteer Long-Term Care Ombudsman Role
The Gerontologist; Vol. 44 (1), 116-120; 2004.
Journal article (research)
In this study, 106 of 135 active volunteers in Oregon's Long-term care Ombudsman Program were surveyed to determine what factors appeared associated with successful program implementation. Volunteers' motives and their satisfaction were considered along with successful outcomes. The majority of the participants were retired (64.2 percent), female (69 percent), white (99 percent), and approximately 40 percent had either a prior personal or familial involvement with the long-term care system. Motivation (broadly categorized as self-development, affiliation, and altruism) and satisfaction were measured using the Self Expression Instrument, and organizational commitment was measured by the 15-item Organizational Commitment Questionnaire. The program's success was measured by the following outcomes: number of monthly complaint reports; facility visits per month; total time committed to the role; and complaints filed against the ombudsmen by providers. All motives were significantly related to satisfaction, with the affiliation motivation being most fulfilling. Ombudsmen with higher organizational commitment spent more time in the role, visiting facilities and filing reports. Although the altruistic motive was less correlated with satisfaction than the other two motives, it was the only predictor of a success outcome (time devoted to the role). One surprising finding was that advanced Certified Ombudsmen had more complaints filed against them. This may be, in part, because they are more assertive in their advocacy and are likely to have more complicated cases to address. This study bears out the significance of organizational commitment in volunteering as it was tied to satisfaction, to all three classes of motivation, and every success outcome measure, except complaints against ombudsmen.


3. P5617-24
Allen, P., Kellett, K. & Gruman, C.
Elder Abuse in Connecticut's Nursing Homes
Journal of Elder Abuse & Neglect; Vol. 15 (1), 19-42; 2003.
Journal article (research)
This study draws upon data tracked by the Connecticut Ombudsman Reporting System from July 1998 through July 2000. Of the 3,443 complaints lodged during this time period, 269 were categorized as abuse, gross neglect or exploitation, while 791 were issues of care. Overall, 47 percent of Connecticut's 261 nursing homes had one or more accounts of abuse. The article also provides an overview of the difficulties of defining elder abuse, and in enforcing established standards of care.

4. P5722-24
Allen, P., Klein, W. & Gruman, C.
Correlates of Complaints Made to the Connecticut Long-Term Care Ombudsman Program
Research on Ageing; Vol. 25 (6), 631-654; November 2003.
Journal article (research)
In this study, researchers explored the correlation between facility characteristics of Connecticut's 261 nursing homes and rates of complaints made to the Long-Term Care Ombudsman Program from 1998-2000. The independent variables of profit status, size, unionization, location, staffing, Medicaid occupancy, health department citations, volunteer placement, and facility care level were analyzed. Complaints were categorized as resident rights issues, care issues (including abuse and neglect), administration issues, or quality of life concerns. A bivariate analysis revealed a correlation between profit size, location, citations, and the presence of a volunteer advocate with higher rates of complaints registered. On a multivariate level, the relationships appear more complex, suggesting that variables other than institutional characteristics impact complaint reporting.

5. P5719-11
Keith, P.
Interests and Skills of Volunteers in an Ombudsman Program: Opportunities for Participation
International Journal of Aging and Human Development; Vol. 57 (1), 1-20; September 2003.
Journal article (research)
Although motivation for volunteering as ombudsmen has been researched, the skills and interests that volunteers bring to the program have not. Using data from applications of 778 volunteers, researchers identified the most common reasons for their interest in participation. Over a quarter of the volunteers wanted to perform community service by assisting older individuals. The second most common reason for interest was having a friend or relative living in a nursing home. Other frequently identified reasons include the need for advocacy, requested participation, and contract with the facility. Participants most frequently identified social skills as personal attributes that would benefit them in this capacity. Other self-reported skills include occupational, listening and personal care skills, leadership and organizational skills, knowledge about the aging process, familiarity with facilities, and advocacy skills. The author also explores the relationship between interests, skills and volunteer characteristics, and considers the implications that this may have for training and education programs.

6. M100
National Long Term Care Ombudsman Resource Center, National Citizens' Coalition for Nursing Home Reform (NCCNHR)
Residents' Rights Tool Kit 24/7: Residents' Rights Around the Clock
National Long Term Care Ombudsman Resource Center, National Citizens' Coalition for Nursing Home Reform (NCCNHR), Washington, D.C.; 2003.
To quote from the introduction, the tool kit is "...full of ideas, activities and resources to promote the dignity and individuality of residents based on the actual work of advocates and staff in the field who work to promote rights. It is full of examples and concepts that your colleagues have found workable and successful. It is our hope that you will use this kit throughout the year as part of your resident and public education efforts..." The kit contains laminated posters depicting residents' rights through daily activities, power point presentations, handouts, and other materials that may be used for the training of residents and families, staff, ombudsmen and others. The kit is contained in an accordion style folder with room for brochures and other customized items. The materials include the Federal Regulations on Residents' Rights, planning tips and sample press releases to promote Residents' Rights week (held in October), train-the-trainer techniques regarding adult education, training strategies (such as the customer service approach), training activities for professionals and advocates (such as "resident for a day"), and a resource list. (Note: This tool kit is available only through National Citizens' Coalition for Nursing Home Reform/NCCNHR at 1424 16th St., NW, Suite 202, Washington, D.C. 20036-2211, telephone 202 332 2275, web address: http://www.nursinghomeaction.org . Price: $30.00 plus $3.00 s/h. Checks made to NCCNHR, or VISA, MC, AMEX.)

7. P5765-20
Office of Inspector General, Department of Health and Human Services
State Ombudsman Data: Nursing Home Complaints (OEI-09-02-00160)
Office of Inspector General, Department of Health and Human Services; July 2003.
Agency report
The purpose of this report is to describe nursing home complaints based upon data collected through the National Ombudsman Reporting System (NORS) from 1996 through 2000. Among the findings, the number of nursing home complaints increased (from approximately 145,000 in 1996 to approximately 186,000 in 2000), but the types of complaints did not change significantly. Over one third of the complaints involved resident care. Analysis of state-specific data from nine states indicates that local ombudsmen do not report complaints uniformly, due to variations in state laws and policies. As a result, the Administration on Aging (AoA) will conduct regional and state training to enhance uniformity of data coding. (Note: This report is accessible online at:
http://oig.hhs.gov/oei/reports/oei-09-02-00160.pdf .)

8. P5718-6
Oswald, S., Runge, A., Lees, E. & Patterson, G.
Texas Certified Volunteer Long-Term Care Ombudsman: Perspectives of Role and Effectiveness
Journal of the American Medical Directors Association (JAMDA); Vol. 4 (6), 323-328; November/December 2003.
Journal article (research)
This article discusses how Texas certified volunteer ombudsmen (CVOs) perceive their roles and effectiveness. Three-hundred sixty-one CVOs representing all 28 regional Texas Ombusdman programs completed surveys regarding demographics, activities, effectiveness and perceived barriers to effectiveness. Focus groups were held in order to supplement survey data. Among the findings, nearly half of the participants believed that they were extremely effective in their role as resident rights advocates and two-thirds believed that they were effective in changing nursing home policies. Ombudsmen with more than five years experience perceived greater effectiveness than those who were new to the program. Three primary barriers were identified by those respondents who reported major obstacles: lack of clarity regarding their position, lack of clarity regarding lines of authority, and lack of power. They also identified a number of facility restrictions as problematic and indicative of mistrust of the Ombudsman's role, such as lack of access to resident records.

9. P5686-21
Payne, B. & Berg, B.
Perceptions About the Criminalization of Elder Abuse Among Police Chiefs and Ombudsmen
Crime & Delinquency; Vol. 49 (3), 439-459; July 2003.
Journal article (research)
Employing general systems theory, researchers analyzed the differences in sanctions favored by police chiefs and ombudsmen, for six different types of elder mistreatment. One-hundred nineteen police chiefs from four states and 203 ombudsmen from 26 states were surveyed by mail. The survey described six scenarios of abuse, including incidents of institutional abuse and neglect as well as incidents of street crime and fraud. Respondents were asked to rank order the perceived appropriateness of four sanctions, ranging from administrative reprimand to fines, probation and jail time. They were also asked to rank order the severity of the offenses. While ombudsmen rated patient offenses as most serious, police chiefs rated street crimes as most severe. In addition, they were also asked for agreement or disagreement on five statements regarding policy in addressing elder abuse. While both groups appear to support the criminalization of elder abuse and agree that it should be a priority of the criminal justice system, they differed as to what sanctions were most appropriate for most offenses.

10. P5431-5
Wood, S. & Stephens, M.
Vulnerability to Elder Abuse and Neglect in Assisted Living Facilities
The Gerontologist; Vol. 43 (5), 753-757; 2003.
Journal article (research)
Assisted living is the fastest growing segment of long-term care in the U.S. It has long been considered a consumer driven market in which consumers (residents) receiving substandard care would "vote with their feet" by choosing alternative placements. This descriptive study explores the vulnerability of assisted living residents to elder abuse and neglect. Twenty-seven, relatively cognitively intact residents participated in this research. The mean age was 87, and 24 of the residents were female. Participants were initially interviewed for a baseline assessment of their knowledge of adult supportive services, including Ombudsman programs. They next viewed a video of 19 scenarios depicting various types of institutional abuse and neglect (two scenarios depicted appropriate care). Following the video, they were asked to develop their own strategies should they be similarly victimized. Of the findings, the participants demonstrated a poor awareness of adult protective services and other supportive services. While they were able to identify abusive situations 54 percent of the time, when asked how they would address abusive situations, 78 percent appeared unable to generate a plan without consulting with family. Among the implications are the need for educating residents regarding adult supportive services and abuse and neglect issues, and the likelihood that residents vulnerable to poor treatment would be unable to change their residence easily.


11. P5725-14
Eisendrath, B.
Reimaging the Ombudsman: An Appraisal: An Ombudsman Program Can Serve as a Useful Alternative to the Court System for Nursing Home Residents
Elder's Advisor; Vol. 3 (3), 49-51; Winter 2002.
Journal article (scholarship)
This article presents an overview of the Ombudsman program in long-term care, which can serve as an alternative to court action for nursing home residents and their families. It describes the history of the term "Ombudsman" and the many roles that are handled by these long-term care advocates in the U.S. It describes changes promoted by ombudsmen, including enhancement of residents' rights, and also presents criticism of the programs, including role confusion, and questionable autonomy. The article highlights the history and development of Wisconsin's program, which espouses a preventative approach that combines site visit consistency with public awareness and education.

12. P5109-16
Keith, P. & Schafer, R.
Expected and Actual Difficulties of Volunteer Resident Advocates in an Ombudsman Program
The Journal of Applied Gerontology; Vol. 21 (4), 421-436; December 2002.
Journal article (research)
This research was designed to compare the difficulties that Ombudsman volunteers anticipated prior to beginning advocacy for long-term care residents with the actual difficulties they experienced once practicing. The study involved 778 participants who advocated for residents throughout 320 nursing homes in a Midwestern state. While 37 percent of those surveyed anticipated "no difficulties," every participant realized some degree of difficulty in the actual role. Time constraints were the most significant problem experienced, reported by 37 percent of the volunteers. While no volunteers anticipated the depressing aspects of the role, 22 percent experienced this once active. Similarly, although no participants anticipated it, communicating with the residents was experienced as problematic by 16 percent, and 14 percent experienced difficulty with the complaint process. One significant implication is that volunteers would benefit from knowing how much time they should expect to dedicate to this role.

13. P5297-6
National Center on Elder Abuse (NCEA), Aravanis, S. (moderator), Dize, V. (speaker) of the National State Units on Aging (NASUA)
Abuse Reports and Investigations in Assisted Living - National Teleconference Highlights
National Center on Elder Abuse (NCEA), Washington, D.C.; February 21, 2002.
Teleconference highlights
This paper presents the highlights of a national teleconference sponsored by the National Center on Elder Abuse (NCEA) on February 21, 2002. The speaker was Virginia Dize, Associate Director for Long-term care Services of the National Association of State Units on Aging (NASUA) and the conference involved over 50 participants including ombudsmen, APS and legal policy developers. The conference began with an overview of the efforts of the national assisted living work group to develop consensus regarding the following six issues: residents' rights, facility ethics, staffing, medication management, affordability, and residents' direct care services and operations. Concerns that were discussed included the changing profile of residents admitted, including an increase in admissions through Medicaid waivers of residents with greater physical and mental care needs. Also, ambiguity over the role of the Ombudsman in assisted living was explored. Good practices regarding legislative initiatives, background checks and abuse registry, and admission agreements (from New Hampshire and Vermont) were outlined.

14. P5760-24
Payne, B. & Gray, C.
Theoretical Orientation and Responses to Abuse in Nursing Homes: A Survey of Ombudsmen from Across the United States
Journal of Social Work in Long-Term Care; Vol. 1 (4), 31-54; 2002.
Journal article (research)
This research was designed to survey ombudsmen throughout the country regarding their theoretical orientation and experiences in addressing elder abuse and neglect in long-term care institutions. Two-hundred and three ombudsmen from 26 states completed mailed surveys regarding the process in which they handle abuse and neglect allegations and the problems they encounter. Problems identified included lack of training, obstacles gathering facts and obtaining witnesses, family denial, and lack of support and authority. Similar to social workers, respondents tended to define elder mistreatment as a rights-centered problem rather than a criminal problem. They tended to recognize the complexity of elder abuse and identified multiple causes such as stress, victim vulnerability, greed, lack of morals (on the part of the perpetrator) and lack of training as the most common causes. Staff characteristics (such as workload, poor background screening, etc.) were also identified. Research suggests that interdisciplinary training among social workers, criminal justice professionals and ombudsmen would be beneficial in reducing barriers to effective investigation and resolution of complaints.

15. P5717-4
Persson, D.
The Ombudsman Program: An Overview of the History, Purpose, and Roles of Ombudsmen in Long-Term Care Facilities
Journal of the American Medical Directors Association (JAMDA); Vol. 3 (4), 270-273; July/August 2002.
Journal article (scholarship)
This article provides an overview and history of the Long-Term Care Ombudsman Program (LTCOP) since its establishment under the Older Americans Act in the 1970's. Three broad functions are identified for the Ombudsman: mediator, advocate, and therapeutic supporter. The article focuses on ways in which nursing home administrators, nurses and physicians can facilitate more effective relationships with the local Ombudsman in order to fully utilize this program as a resource for improvement of long-term care service delivery. Recommendations include providing in-service education for all staff regarding the LTCOP, and opportunities to allow all staff members to meet the local representatives.


16. P5575-19
Filinson, R.
Evaluation of the Impact of a Volunteer Ombudsman Program: The Rhode Island Experience
Journal of Elder Abuse & Neglect; Vol. 13 (4), 1-19; 2001.
Journal article (research)
In 1995, a study by the Institute of Medicine revealed that Rhode Island, although it has the highest proportion of institutional facility beds in New England, had the third lowest ratio of designated ombudsmen for its nursing home population. At that time, it had one paid Ombudsman to advocate for 11,147 residents, with no additional volunteers. In 1997, Rhode Island implemented a volunteer component to the state's program, which was then placed under the supervision of a citizen's watch group, the Alliance for Better Long-Term Care. Data analysis of complaints reported to the state Ombudsman's office indicates that volunteer presence in nursing facilities was associated with higher rates of complaints filed. It also revealed that the nature of the complaints filed were of a greater degree of seriousness. Demographic and facility characteristics in relation to rates of complaints are also discussed.

17. P5721-8
Huber, R. et al.
National Standards for the Long-Term Care Ombudsman Program and a Tool to Assess Compliance: The Huber Badrak Borders Scales
The Gerontologist; Vol. 41 (2), 264-271; 2001.
Journal article (research)
This article presents the Huber Badrak Borders Scales, which were based upon the Institute of Medicine's best practices guidelines for Long-term Care Ombudsman Program (LTCOP) standards. The tool is intended to evaluate the performance of the program (not the local Ombudsman) and assesses program areas such as structure, qualifications of participants, legal authority, resources (human, legal and financial), management information systems, resident and systemic advocacy services, and educational services. The tool was pilot-tested in Kentucky in 1996 and then, following revisions, implemented again in 1999. The reassessment indicated that progress was made in nine program areas.

18. P5075-8
Huber, R., Borders, K., Netting, F. & Nelson, H.
Data From Long-Term Care Ombudsman Programs in Six States: The Implications of Collecting Resident Demographics
The Gerontologist; Vol. 41 (1), 61-68; 2001.
Journal article (research)
One sociological theory, the "leveling theory," proposes that social inequities are mitigated by aging issues, while the "double jeopardy" theory suggests that aging exacerbates such social inequalities. This article reports upon research that was designed to examine the value of collecting demographic information on ombudsmen reporting documentation. Using the National Ombudsman Reporting System (NORS), 23,787 complaints were analyzed from six states (1996) to identify any possible links between gender, race and types of complaints lodged, verified and completely resolved. The findings indicate that a higher percentage of minorities (all residents not identified as Caucasians) had verified complaints; however, a lower percentage of these complaints were fully resolved. Information regarding the specific types of complaints most frequently lodged by which age-gender group is included.

19. P5724-17
Keith, P.
Correlates of Reported Complaints by Volunteers in an Ombudsman Program
Journal of Elder Abuse & Neglect; Vol. 13 (3), 43-59; 2001.
Journal article (research)
This study examines the relationship between perceptions of volunteer ombudsmen and facility characteristics in association with number of resident complaints reported by volunteers. Six-hundred thirty-three volunteers were surveyed regarding demographic characteristics, social-psychological factors, role orientation, views regarding the Ombudsman program, and attitudes and behaviors attributed to nursing facility staff. In examining results related to role orientation, findings indicate that those volunteers who viewed themselves as advocates (versus therapeutic supporters) reported higher numbers of complaints, while those acquainted with nursing home staff reported fewer complaints. In analysis of results regarding perceptions of volunteers, those who viewed administration as unsupportive and held negative views of long-term care filed higher numbers of complaints. Recommendations for recruitment and training of volunteers based upon these findings are presented.

20. N4795-8
Keith, P.
Role Orientations, Attributions to Nursing Facility Personnel, and Unresolved Complaints of Volunteers in an Ombudsman Program
Journal of Gerontological Social Work; Vol. 34 (4), 33-46; 2001.
Journal article (research)
This research explores the Ombudsman volunteers' perspectives regarding the level of support they receive from nursing facility personnel as they address complaints of abuse and deficiencies in care. Early research suggests that the volunteer's orientation (that of advocate, therapeutic supporter, mediator or educator) may have a link to nursing facility personnel's behaviors towards them. Two hypotheses were addressed: (1) advocates attribute more negative attitudes and hindrances to facility personnel and feel less effective than do mediators or therapeutic supporters; (2) attribution of higher levels of negativity and hindrances from facility staff, and less effectiveness in resolving complaints, are associated with more unresolved complaints. A sample of 481 volunteers from eight Area Agencies on Aging from a Midwestern state participated in this study. The findings indicate that those volunteers who viewed themselves as advocates tended to have more negative relationships with facility personnel than volunteers self-identified as friendly visitors. Advocates also indicated that such negativity had an impact upon unresolved complaints.

21. P5720-8
Keith, P.
Support from Others and Efficacy of Volunteer Ombudsmen in Long-Term Care Facilities
International Journal of Aging and Human Development; Vol. 52 (4), 297-310; 2001.
Journal article (research)
In this study, 607 volunteer ombudsmen were surveyed regarding their perceptions of support from ten different sources and the impact that such support had upon their effectiveness in advocacy and promoting positive changes in the long-term care setting. Findings indicate that 55 percent of the ombudsmen received a great amount of support from nursing home administrators. Fellow volunteers, Area Agency on Aging personnel, family members and aides also provided assistance. Assistance provided by administrators was perceived as having the greatest impact upon the ombudsmen's efficacy, along with support from residents. However, support from nurses and aides appeared to have no impact upon perceptions of efficacy, and support from fellow volunteers appeared negatively associated with feelings of efficacy.

22. P5046-48
Murtiashaw, S. for the National Long Term Care Ombudsman Resource Center
Ombusdman Initiatives Addressing Neglect and Abuse
National Long Term Care Ombudsman Resource Center, for the Administration on Aging, Department of Health and Human Services, Washington, D.C.; January 2001.
Agency report
As quoted from the Introduction: "The Ombudsman Initiative Addressing Abuse/Neglect details information on how long-term care Ombudsman programs have successfully impacted neglect and abuse in long-term care facilities. Thirteen (13) programs were identified that have developed different approaches to combating abuse and neglect..." Programs from the following states are outlined as promising: California, Colorado, Georgia, Maryland, Michigan, Missouri, Nevada, New Mexico, New York, North Carolina and Washington. Topics covered include information strategies to prevent and combat elder abuse, quality of care, nutrition, and services to nursing home residents who are victims of crime. (Note: This article is available online at http://www.ltcOmbudsman.org/uploads/AbuseInitiativeJan01.pdf)

23. P5723-17
Nelson, H., Netting, F., Huber, R. & Borders, K.
The Social Worker-Ombudsman Partnership: Using a Resident-Centered Model of Situational Conflict Tactics
Journal of Gerontological Social Work; Vol. 35 (3), 65-81; 2001.
Journal article (scholarship)
Observing that long-term care social workers are often assigned multiple tasks, leaving little time for resident advocacy, the authors of this article present a protocol that allows coordination with the Ombudsman in order to address conflicts occurring within the facility. The resident-centered situational conflict model involves such tactics as appealing to service providers for help, and assessing the facility's level of resistance. Other strategies include avoidance, conciliation, or collaborative strategies such as compromise, education, negotiation and advocacy mediation. The article also presents discussion of two contest strategy tactics: argumentation, in which the advocate points out to a service provider the "proof" of a wrong (violation of regulations, etc.); and warning-referral to an external authority, such as a family council, adult protective services, or a court system.

24. P5759-18
Nelson, H., Netting, F., Huber, R. & Borders, K.
Training Residents' Rights Case Advocates in Effective Situational Conflict Skills
Gerontology & Geriatrics Education; Vol. 22 (2), 29-46; 2001.
Journal article (scholarship)
The need for a two-phased, situational training model for ombudsmen is presented in this article. Five basic conflict tactics are described as they apply to the role of Ombudsman as resident advocate: forcing, compromise, conciliation, avoidance, and problem-solving. The first phase of training involves the development of self-awareness regarding the advocate's personal conflict habits and attitudes and education regarding the appropriate tactics for specific situations. Phase two involves skills training through repeated practice and role-playing using hypothetical scenarios typical of long-term care conflicts.

25. P5098-9
Payne, B.
Understanding Differences in Opinion and 'Facts' Between Ombudsmen, Police Chiefs, and Nursing Home Directors
Journal of Elder Abuse & Neglect; Vol. 13 (3), 61-77; 2001.
Journal article (research)
Noting the importance of interdisciplinary/multidisciplinary responses to elder abuse and neglect in institutional settings, this research examines possible philosophical differences or misunderstandings among police chiefs, ombudsmen and nursing home directors. Two questions are considered: (1) Do these professional groups differ in their opinions about elder mistreatment issues; and (2) Do these groups differ in their knowledge regarding such issues? Gender differences are also considered. Seventy-three nursing home professionals, 119 police chiefs, and 203 ombudsmen from Alabama, California, Colorado, and New York completed a survey designed to assess perceptions of and knowledge regarding elder abuse. Seven sub-scales are included: crime facts, nursing home facts, crime and punishment opinions, media prevention opinions, victim attribution issues, an opinion scale, and a fact scale. Of the differences observed, nursing home directors were more likely to attribute blame to the victims than the other professional groups, and males were more likely to blame the victims, to see nursing homes as unsafe, and less likely to view elder abuse as problematic. Knowledge of these differences can be used to enhance communication, cooperation and coordination among these professionals.


26. P5028-26
Atlanta Legal Aid Society
The Silenced Voice Speaks Out
Atlanta Legal Aid Society; 2000.
Agency report
In this research, ombudsmen in the Atlanta, Georgia region hypothesized that nursing home residents are often dismissed as unreliable witnesses to abuse and/or neglect. Further, they hypothesized that the Office of Regulatory Services (ORS) investigations are not thorough and do not provide adequate relief. From 11/1999 through 9/2000, researchers interviewed residents from 23 facilities regarding their experiences and observations of abuse and neglect. Ombudsmen then referred and tracked 71 cases of abuse/neglect to the ORS. Only three percent were verified and adequately redressed with appropriate citations. Among the findings of this survey, 38 percent of the respondents had witnessed abuse, 56 percent of these residents reported the mistreatment, and 32 percent of those reporting felt that reporting had been effective. Appendices of the report include research protocols and residents' definitions of abuse and neglect. (Note: This report is available online at http://www.atlantalegalaid.org/abuse.htm .)

27. P5764-20
Huber, R., Borders, K., Netting, F. & Kautz III, J.
Interpreting the Meaning of Ombudsman Data Across States: The Critical Analyst-Practitioner Link
Journal of Applied Gerontology; Vol. 19 (1), 3-22; March 2000.
In this article, the authors compare and examine data from four state Long Term Care Ombudsman Programs (LTCOPs) that use the same report tracking software. They stress the importance of analyzing such data with sensitivity to the uniqueness of the structure of the LTCOP (as well as the practitioner) reporting data. Differences in state legislation and definitions of elder abuse, jurisdiction of abuse investigation, and coding practices are among the variables that reflect differences in trends identified across programs, and can reflect inaccurately on programs evaluated. Initiatives led by the Administration on Aging (AoA) to improve consistency of data coding and coordinated efforts across interstate regions are recommended as methods to enhance the consistency and usefulness of the data collected.

28. P5023-9
Hunt, S., for the National Long Term Care Ombudsman Resource Center
The Long Term Care Ombudsman Program Unique Characteristics
November 2000
Online publication
Since its inception in 1972, the role of the Long Term Care Ombudsman Program (LTCOP) has been that of advocacy for residents of nursing homes and other residential care facilities. This paper provides a brief history of the evolution of the LTCOP and discusses distinctions between this and other programs serving older Americans. Topics covered include the adaptation of the classic Ombudsman model, distinctions within the aging network and accountability. (Note: This paper is available online at

29. P5761-12
Keith, P.
Correlates of Primary Orientations of Volunteer Ombudsmen in Nursing Facilities
Journal of Aging Studies; Vol. 14 (4), 373-384; 2000.
Journal article (research)        
In this study, 745 volunteer ombudsmen from a Midwestern state were surveyed regarding their primary orientation to volunteer work as being either that of advocate, mediator, therapeutic supporter or undifferentiated. Implications of their orientation were also studied. Participants were also questioned regarding their formal training, about their sense of inequity within their interactions, and about the hindrances they experienced in attempting to fulfill their responsibilities. Most participants identified themselves as therapeutic supporters (55 percent), followed by advocates (22 percent), mediators (13 percent), with only 10 percent unable to identify their primary orientation. Advocates tended to be younger, more educated, and experienced less of a sense of inequity than volunteers of other orientations. Therapeutic supporters were predominantly women who experienced a sense of equity within their volunteer roles. Those volunteers without a theoretical orientation were older, with less formal education and less in-service training, and experienced fewer hindrances in executing their tasks. However, this group experienced a greater sense of inequity and felt most unappreciated. The author describes ways in which training and education could benefit volunteers of various orientations.

30. P5762-23
Nelson, H.
Injustice and Conflict in Nursing Homes: Toward Advocacy and Exchange
Journal of Aging Studies; Vol. 14 (1), 39-61; 2000.
Journal article (scholarship)
Using the theoretical framework of social exchange, this article analyzes the dynamics of power and dependence within conflicts in long-term care settings. Key concepts of the theory, such as autonomy/fate control and mobility are considered. Due to power imbalance, "normal conflict" resolution tactics (such as bargaining) are not possible. Dynamics that contribute to the conflict escalation and negativity that sometimes accompany the presence of a third party advocate, such as a volunteer or paid Ombudsman, are examined. The need for such advocacy is also described. The author argues that when competitive strategies fail to induce adequate complaint resolution on the part of the provider, coercive strategies are justified.

31. P5747-20
Netting, F. et al.
Volunteer and Paid Ombudsmen Investigating Complaints in Six States: A Natural Triaging
Nonprofit and Voluntary Sector Quarterly; Vol. 29 (3), 419-438; September 2000.
Journal article (research)
This research compares differences in trends observed in the way that volunteer ombudsmen and paid staff investigate and address complaints. Researchers focused on differences in types of complaints, in the source and disposition of complaints, and in the degree of complexity among complaints investigated by each group. Data was analyzed from 22,543 complaints reported across six states and tracked in the National Ombudsman Reporting System (NORS). Complaints are categorized under five general headings: resident rights (which includes physical and sexual abuse, financial exploitation, and neglect); resident care (hygiene, symptoms unattended, etc.); quality of life (such as environmental issues); administrative functions (staffing issues, access to information, etc.); and complaints against entities outside of the facility (such as Medicare, protective services, etc.). Two-hundred and fourteen volunteers investigated 6,388 complaints and 71 paid staff addressed 16,155 complaints. Volunteers investigated a higher percentage of routine complaints, while paid staff investigated a higher percentage of complex cases. Among other findings, employees who were paid were more likely to handle issues concerning resident rights, while volunteers were more likely to investigate issues of resident care. Verification rates were higher among volunteer investigations (84 percent, compared to 72 percent among paid staff investigations). Volunteers reported a higher percentage of fully resolved cases (61 percent, compared to 49 percent of those investigated by paid staff), while paid staff reported a higher rate of partially resolved complaints (35 percent, compared to 27 percent of the volunteer investigated.)


32. P5763-11
Arcus, S.
The Long-Term Ombudsman Program: A Social Work Perspective
Journal of Gerontological Social Work; Vol. 31 (1/2), 195-205; 1999.
Journal article (scholarship)
This article presents ways in which the social work perspective can be incorporated into the Ombudsman's role in order to foster a transition from the traditional, medical model of long-term care to the emerging social model. The social model is resident-centered, holistic, and emphasizes wellness. In particular, the author suggests that the Ombudsman could promote greater facility-community interaction. Highlights from the Pima County Long-Term Care Advocacy Program (LTCAP) are presented to illustrate the approach.

33. P5766-26
Office of Inspector General, Department of Health and Human Services
Long Term Care Ombudsman Program: Complaint Trends (OEI-02-98-00350)
Office of Inspector General, Department of Health and Human Services; March 1999.
Agency report
In order to examine trends among Ombudsman program complaints, data from ten state programs was tracked and analyzed. Data from 1989 through 1997 (excluding data from 1995 due to a transition in tracking systems) indicates an increase in annual complaints reported from approximately 58,000 to approximately 65,000. Data from 1996 through 1997 indicates an increase in complaint per resident bed ratio from 65 complaints per 1,000 to 69 complaints per 1,000, with most complaints concerning resident care (32 percent) and resident rights (31 percent). Issues regarding staff turnover, staff training, poor hygiene, physical abuse, and improper handling were among the top ten complaints reported in 1997. (Note: This report is accessible online at: http://oig.hhs.gov/oei/reports/oei-02-98-00350.pdf)

34. P5767-25
Office of Inspector General, Department of Health and Human Services
Long Term Care Ombudsman Program: Overall Capacity
Office of Inspector General, Department of Health and Human Services; March 1999.
Agency report
The purpose of this report is to describe the overall capacity of State Long Term Care Ombudsman Programs (LTCOPs) to "promote and monitor quality of care in nursing homes." Program data (1997) from the National Ombudsman Reporting System (NORS) for ten states with the largest nursing home population was analyzed. Phone interviews and review of written program procedures were also conducted. Among the findings, the program's effectiveness is limited by staffing constraints and a lack of common standards for addressing and resolving complaints. Recommendations generated include the need for the Administration on Aging (AoA) to collaborate with the states in developing "guidelines for a minimum level of program visibility," including frequency and length of visits, and a ratio of staff per resident beds; developing strategies for recruiting, training and supervising volunteers; developing time frames for response and resolution of complaints; and enhanced collaboration among Ombudsman programs, surveying and certification agencies. (Note: This report is accessible online at: http://oig.hhs.gov/oei/reports/oei-02-98-00351.pdf)


35. P5758-12
Huber, R., Borders, K., Netting, R. & Kautz III, J.
To Empower with Meaningful Data: Lessons Learned in Building an Alliance Between Researchers and Long-Term Care Ombudsmen
Journal of Community Practice; Vol. 4 (4), 81-101; 1997.
Journal article (scholarship)
This article reports upon an effective collaboration between a research team and a state Ombudsman program that resulted in the development of a national database to track resident complaints. Input from local ombudsmen as well as state administrators was solicited so that information collected in the database reporting system was practical for both program evaluation as well as enhanced service delivery. Modifications in the OmTrak software were incorporated to allow customized data reporting for individual states.


36. J4005-8
Huber, R., Netting, F. & Kautz, J.
Differences in Types of Complaints and How They Were Resolved by Local Long-Term Care Ombudsmen Operating in/Not in Area Agencies On Aging
Journal of Applied Gerontology; Vol. 15 (1), 87-101; March 1996.
Journal article (research)
The aging population is changing daily, requiring an understanding for new complexities. This study represents a beginning in the examination of differences and similarities between Ombudsman programs located in Area Agencies on Aging and non-Area Agencies on Aging.


37. I3642-291
Feasley, J. & Estes, C., eds., for the Institute of Medicine
Real People Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act
Committee to Evaluate the State Long-Term Care Ombudsman Programs, Division of Health Care Services, Institute of Medicine; Washington, D.C.; 1995
Agency report
This report evaluates the effectiveness of the Long-Term Care Ombudsman Program (LTCOP), which initially began in 1972 through state demonstration projects, and is now under the auspices of the Administration on Aging. The evaluation addresses the programs compliance with federal mandates, the accessibility of the program to long-term care residents, the adequacy of federal and other resources to support the program, and the need for such advocacy for older individuals not residing in long-term care facilities. Among other sources, the report was based upon information gathered through site visits, commissioned papers, and the input of ombudsmen and other representatives of the aging field. Recommendations to enhance program effectiveness are identified.
(Note: This is not available through CANE.
It may be viewed online at http://www.nap.edu/books/NI000028/html/ .)

38. J3877-6
Nelson, H., Huber, R. & Walter, K.
The Relationship Between Volunteer Long-Term Care Ombudsmen and Regulatory Nursing Home Actions
The Gerontologist; Vol. 35 (4), 509-514; 1995.
Journal article (research)
This study confirmed the hypotheses that nursing facilities with assigned volunteer ombudsmen demonstrated more abuse complaints and substantiated abuse complaints, greater sanction activity, and more survey deficiencies than facilities without assigned ombudsmen. It is the first to systematically assess ombudsmen effectiveness by external criteria since the program was strengthened by the 1987 Older Americans Act reauthorization. (Oregon)

Additional Resources
The National Long Term Care Ombudsman Resource Center (ORC, online at http://www.ltcombudsman.org) is dedicated to providing support, education and training, and technical assistance to the states' Long Term Care Ombudsman Programs (LTCOP). With funding from the Administration on Aging (AoA), the Center is operated by the National Citizens' Coalition for Nursing Home Reform (NCCNHR), in cooperation with the National Association of State Units on Aging (NASUA). The ORC library provides electronic access to a wealth of publications, reports, and resource documents designed to enhance the performance of LTCOPs. The following list of NASUA publications are among the resources that can be accessed from the ORC web site:

Resource Brief: Ombudsman Program Data Management Systems (July 2004). http://www.ltcombudsman.org/uploads/OmbProgDataMnagmnt0704.pdf

Long-Term Care Ombudsman Program: Ombudsmen Talk about
Guardianship (February 2004).

Ombudsman Best Practices: Enhancing Consumer Access through
Coordination Focus: Ombudsman and Aging I&R/A Programs (January 2004). http://www.ltcombudsman.org/ombpublic/251_1341_8015.cfm

Long-Term Care Ombudsman Program: Structure, Responsibilities,
Quality and Funding (September 2003).

Volunteer Consultants: Extending the Reach of Ombudsman Programs
(May 2003).

Long-Term Care Ombudsman Program: A Summary of State Enabling
Statutes (April 2002).

The Role of the Long Term Care Ombudsman Program in Home Care
Advocacy (June 2001).

Obtaining Medicaid Funding For The Long Term Care Ombudsman
Program: The Experience of Eight States (June 2001).

Ombudsman Advocacy Challenges in Assisted Living: Outreach and
Discharge (March 2001).

Use of Mediation in Assisted Living --- and Some Advice Thrown
In: An Ombudsman Training Module (February 2001).

To review the most recent LTC reports as well as national and state data, visit the Administration on Aging web site at:

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