What is an Ombudsman?

The word ombudsman (om-budz-man) is of Swedish origin, and means a person who speaks on behalf of another. The Missouri Long-Term Care (LTC) Ombudsman Program is a statewide network of individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected.

Ombudsman Roles

Ombudsmen have many different roles in their work:

  1. Facilitator: Helping people formulate or simplify problems and complaints.
  2. Educator: Providing materials and resources to residents, facility staff, families, and the community at large that encourage and support self-help and problem solving.
  3. Broker: Making referrals and following through until the problem is solved.
  4. Intermediary: Promoting communication among those involved in a problem.
  5. Collaborator: Working with residents and staff toward mutually beneficial solutions.
  6. Mediator: Bringing together all pertinent individuals to arrive at an agreement or a compromise.
  7. Advocate: Acting on behalf of someone else.
  8. Investigator: Gathering pertinent information from many sources in order to evaluate facts objectively.
  9. Problem solver: Resolving problems and complaints from residents.
  10. Negotiator: Arranging for differing parties to discuss their issues and providing an objective viewpoint.

Ombudsman Program Description

Missouri's ombudsman program is a network of ombudsmen volunteers serving residents of nursing homes and residential care facilities to provide support and assistance with their problems or complaints. Individual ombudsman volunteers are recruited by regional ombudsman coordinators in their local ombudsman programs, operated by the Area Agencies on Aging (AAAs) or their service providers. Following screening and training, the volunteer ombudsman is assigned to a facility or facilities. The volunteer becomes familiar with the facility and its procedures and then begins regular visits with the residents.

As residents get to know the ombudsman volunteer, they are able to discuss complaints and concerns with the volunteer. The volunteer helps the residents to work through their issues, and helps them become empowered to resolve complaints.

Data about the types and numbers of complaints, and whether they were resolved to the satisfaction of the resident are reported to the HHS Adminstration on Community Living, Administration on Aging, through the Office of the State Long-Term Care Ombudsman and Regional Ombudsman programs.

History of Nursing Home Care

The provision of nursing care can be traced back through the centuries. In the early first century A.D., the Roman Empire allowed Christians to build facilities to get the sick, poor, and aged off the streets.

Beginning in the 1800s, physicians started the practice of visiting patients in health care facilities. But these facilities were crude answers for caring for the sick and aged. In America, the facilities for meeting the needs of indigent, infirm and elderly people became known as the "poor farm" or the "county home."

The nursing home industry, as we know it now, 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. This spurred the growth of private and non-private institutions and homes. The 1950 amendments to the Social Security Act extended OAA into public medical institutions, and that accelerated the transition of people from public institutions to private and not-for-profit institutions.

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

History of the Ombudsman Program

The long-term care industry grew fast during the 1960s with little regulation. After 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 other department agencies to establish nationwide standards for nursing home construction, care, and operation.

In 1972, the Long-Term Care Ombudsman Program was formed 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 (HHS), is the federal agency charged with responsibility for coordinating programs that benefit the elderly. AoA, now part of the Administration for Community Living in the HHS, 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 enable 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 Americans Act significantly strengthened the program's ability to advocate on behalf of residents in long-term care facilities.

Missouri Ombudsman Program Structure

The Missouri Division of Senior and Disability Services, 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 (SLTCO) is the highest reporting authority for the state and local ombudsman programs. The State Long-Term Care Ombudsman coordinates 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 agencies to promote the ombudsman program and represent the interests of long-term care residents.

Missouri's ten Area Agencies on Aging administer the program on the local level by designating regional ombudsman coordinators. This coordinator may be an Area Agency on Aging staff person or may be a person who works under contract 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 periodic meetings hosted by the State Ombudsman. There, they exchange information and receive training.

The volunteer ombudsmen at the local level are 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 when specific technical information is needed, or when the problem is a system-wide problem.

When facility staff hear the term "The State," they most likely think of the Section for Long-Term Care Regulation (SLTCR) regional surveyors (often called state inspectors). These are staff who are responsible for conducting surveys approximately every 12 months in all facilities. Following each survey, facilities learn of problems or areas of concern that must be corrected to stay in compliance with federal and Missouri statutes and regulations.

The Regional Ombudsman Coordinator regularly interacts with the survey staff. Prior to beginning a survey, the SLTCR Regional Manager consults 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 helpful in steering the inspector to situations that may need to be addressed.

The Regional Ombudsman Coordinators also have contact with the Division of Senior and Disability Services toll-free hotline, where callers can report abuse, neglect, or financial exploitation.

Title III Older Americans Act

Chart showing agencies responsible for implementing programs for the elderly

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 volunteer model operates on the principle that knowledge of a particular facility enables the regular volunteer ombudsman to handle problems more effectively. And when the volunteer ombudsman has an established relationship with the residents and staff, resolution is easier. Ombudsmen assume the role of confidant to the residents, and therefore, residents are more likely to express concerns that might not otherwise surface.

Ombudsmen provide a personalized approach to their work. Regular contact with residents builds trust, visibility and clarity of purpose.

The focus of the ombudsman efforts is resident-initiated complaints. While complaints may be made on behalf of residents by other individuals, ombudsmen are careful that such complaints accurately reflect the concerns of the resident.

Complaints are received in the strictest of confidence. Investigation and resolution are not attempted without the resident's permission. An exception to this might be a problem in the nursing home that affects more than a single resident, allowing the ombudsman to begin to work on the problem without revealing which resident or residents expressed the concern. No problem is too big or too small for the ombudsman to deal with. In fact, ombudsmen can often solve a little problem before it grows serious.

A key concept in this program is the word "empower." To empower is to enable or permit some action. Ombudsmen 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 a patronizing part of the problem.

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 so 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.
  • To advocate for residents rights.
  • To provide community education regarding long-term care facility issues.

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 their Regional Ombudsman Coordinator to provide suggestions for relaying non-confidential information to the community on residents needs and concerns.