Copyright 1992 by The Cerontological Society of America The Cerontologist Vol. 32, No. 6, 843-848
Using paid staff and/or volunteers, long-term care ombudsman programs are charged with resolving complaints and solving problems that affect elderly persons in a variety of long-term care settings. This paper reports the results of a content analysis of annual ombudsman program reports sent to the Administration on Aging from 49 states in 1990. We found substantial variation in the documented information at both state and local levels and recommend revising the reporting system. Key Words: Data collection, Long-term care, Ombudsman
F. Ellen Netting, PhD,2 Ruth Nelson Paton, PhD,3 and Ruth Huber, PhD3
findings regarding the types of problems . . . of individuals residing in long term care facilities, and to provide policy, regulatory, and legislative recommendations to such problems, resolve such complaints, and improve the quality of care and life in long term care facilities. (NASUA, 1988, p. 37)
The Long-Term Care Ombudsman Program is mandated through Section 307(a) (12) of the Older Americans Act (OAA). State agencies on aging are required to establish and operate either directly, through contract, or other arrangement an Office of the State Ombudsman. This office is responsible for investigating and resolving the complaints of long-term care residents, developing protocols for the ombudsman's access to facility and patient records, establishing a statewide reporting system, assuring client confidentiality, monitoring public long-term care regulations and policies, and providing information on problems affecting older persons in longterm care (Berry, 1990). There are 578 substate Ombudsman programs nationally (Berry, 1990). Flexibility in ombudsman program design is encouraged by the Administration on Aging (AoA) so that appropriate models emerge in different state and substate programs. The literature indicates that models used in different states vary by structure, approach, and staffing (Berry, 1990; Monk, Kaye, & Litwin, 1984; National Association of State Units on Aging, 1988). However, all states are required to
Amendments to the OAA have increasingly strengthened the role of the Long-Term Care Ombudsman Program. The 1991 reauthorization of the act will continue this trend, seeking to increase coordination between ombudsman services, legal assistance programs, and protection and advocacy programs. Federal policymakers are increasingly relying on the Ombudsman Program to provide a community presence for residents in both nursing and board and care homes. This reliance is reflected in the OBRA 1987 Nursing Home Reform Act amendments that require that nursing home residents have direct and immediate access to ombudspersons when protection and advocacy services become necessary. It is also reflected in the 1991 Roybal Board and Care Reform Act, now in Congressional Committee, which requires notification of ombudspersons when facilities are not compliant with the Act's provisions. The requirement that each state develop a statewide complaint reporting system is significant because ombudspersons are increasingly involved in the oversight of both nursing and board and care homes. They are also important sources of information and referral in the aging network. Documentation of what happens in their interactions with residents and other state agencies has implications for program and policy development. The ombudsman complaint data base could provide practitioners, researchers, and policymakers with valuable information on resident concerns. In this paper we report the results of a year-long study of reports to AoA and state-level complaint
submit data on complaints and conditions to the Administration on Aging and to the state licensing or certifying agency on a regular basis. The 1987 Amendments to the Older Americans Act pertaining to the Ombudsman Program added further reporting requirements. These include: preparing an annual report containing data and 1 Special appreciation goes to Tina Liu for her valuable assistance in this research. The authors especially thank Elma Holder, Barbara Frank, and Sara Burger from NCCNHR; Cathy Schiman from NASUA; William F. Benson from the Senate Committee on Labor and Human Resources Subcommittee on Aging; and Sue Wheaton at the Administration on Aging for their advice and support during this project. ^Associate professor, Arizona State University School of Social Work, Tempe,AZ 85251-1802. 'Assistant professor, Kent School of Social Work, University of Louisville, Louisville, KY.
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The Long-Term Care Ombudsman Program: What Does the Complaint Reporting System Tell Us?1
reports by state ombudsman programs to determine what the current reporting system tells us. Methods
Results
Because state programs publish their reports according to varying fiscal years, the data reported in this paper reflect the most recent report issued by individual states as of May 1991. These data reflect complaints and activities for state ombudsman programs during the 1989-1990 fiscal year. In 1990, 49 states were using the AoA reporting categories to categorize complaints, but states varied in how they utilized these categories and subcategories. For example, Connecticut breaks out 603 abuse complaints under resident care so that these complaints will not be subsumed under one broad category. Other states provide a more detailed overview of complaint reporting. A total of 134,612 complaints were reported by 49 states and the District of Columbia. The largest complaint category was resident care, with a total of 38,128 complaints reported. Resident care encompasses 29 subcategories including all aspects of abuse and neglect. Examples of subcategories under resident care are inadequate hygiene care, not dressed, physical abuse, and neglect (see Figure 1). Fewer states (42) used the remainder of the AoArecommended reporting form, which requests (1) the percentages of complaints investigated by ombuds-
Resident care
Table 1. Ombudsman Program Complaint Categories on AoA-Recommended Reporting Form
38.1
Physician services ' • 2.9
A. Resident Care (29 subcategories including items such as not dressed, physical abuse, neglect, staff poorly trained, inadequate care plan, and clothing in poor condition) B. Physician Services (7 subcategories including items such as schedule of visits and not responsive in emergency) C. Medications (6 subcategories including items such as not given according to orders and oversedation) D. Financial (9 subcategories including items such as bill/accounting wrong or denied, and questionable . charges by facility) E. Food/Nutrition (15 subcategories including such items as cold, not assisted in eating, no water available, and unsanitary) F. Administrative (15 subcategories including such items as understaffing, roommate conflict, and laundry procedures) G. Resident Rights (26 subcategories including such items as no grievance procedures, denied rights, and violation of privacy) H. Building, Sanitation, Laundry (16 subcategories including such items as cleanliness, pests, and lighting) I. Not Against Facility (13 subcategories including such items as Medicaid reclassification, Medicare, and family problems)
Medications ~~H 4 Financial ~ ^ | 4.9 Food/nutrition Administration Resident rights Building Not against facility
18.7 0
10
20
30
40
50
(In Thousands) Figure 1. Number of ombudsman complaints nationwide by AoA categories (1990).
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In conversations with staff at the National Association of State Units on Aging (NASUA) and the National Citizens Coalition for Nursing Home Reform (NCCNHR), who jointly direct the AoA-funded National Aging Resource Center on the Long-Term Care Ombudsman Program, and with ombudspersons at both the state and substate levels, we learned that states were very diverse in how they collected, analyzed, and reported data on complaints received by state and substate ombudspersons. Some states developed very elaborate annual reports, whereas others penciled in their reports on AoA-recommended reporting forms and some states did not use AoA reporting forms at all. The recommended form contains 136 complaint types organized into 9 categories. Although the AoA form provides space for reporting totals in each category, there are numerous subcategories. Table 1 lists the AoA complaint categories and the number of subcategories for each. In August 1990 we wrote a letter to all state ombudsman programs, specifically requesting copies of their (1) most recent state-level annual report, (2) AoA report, and (3) state-level forms used to document ombudsman complaints and activities. After two follow-up letters were mailed, a research assistant began telephone follow-ups in November. Some states were called as many as five times. By May 1991, all but one state had responded. A systematic content analysis of these reports was conducted. AoA complaint categories were analyzed first. Some states expanded the complaint categories
on the AoA form, whereas a few integrated the AoA categories into more elaborate annual reports. Over half the states (27) reported more information than was required by AoA. Data elements collected by each state were extracted in order to identify patterns across states. Narrative was content-analyzed to identify themes and issues across state-level reports.
person staff and/or other agencies; (2) resolution of complaints; and (3) the percentage of complaints against various types of facilities. Investigation means that an ombudsman volunteer or staff person actually opened a case and took some action to see whether the complaint could be verified. Complaints by Investigators Because the AoA reporting form does not distinguish between paid and volunteer staff, "ombudsman staff" includes both paid personnel and volunteers. Percentage of total complaints investigated by the staff ranged from 100% in Vermont (n = 400) to 20% in Kansas (n = 228). Numbers of complaints investigated by the ombudsman staff ranged from 97 in Alaska to 7,047 in Massachusetts, but it should be noted that Alaska had one full-time staff person, 30 part-time staff, and no volunteers (31 total), whereas Massachusetts had 26 full-time paid staff, 14 parttime staff, and 140 volunteers (180 total) (Schiman & Lordeman, 1989a, p. 25). Obviously, geographical space and population density vary tremendously between these two ends of the continuum. The percentage of total complaints investigated by agencies other than the state unit on aging or area agencies on aging ranged from 80% in Kansas (n = 913) to 0% in Massachusetts, Mississippi, New Jersey, Tennessee, and Vermont. Those complaints jointly investigated by ombudsman staff and other agencies ranged from 60% in Maine to 0% in Georgia and Washington. Nationally, the number of complaints investigated by ombudsman staff alone was 69,023 (78%), by state agencies alone 10,505 (12%), and jointly investigated 9,017 (10%).
Complaint Targets AoA reporting categories for target of complaint are: (1) skilled or intermediate facilities, (2) board and care facilities, (3) regulatory or reimbursement agencies, and (4) others (e.g., guardians, family, and others). The greatest percentage of complaints (79% overall) was lodged against skilled or intermediate nursing facilities, ranging from 98% in Texas (n = 5,301) to 14% in Alaska (n = 36). For the 41 states reporting on target categories, 69,949 complaints were against skilled or intermediate nursing facilities. Complaints against board and care facilities ranged from 41% (n = 599) in Arizona to 0% in Illinois, Nebraska, and Texas. For the 41 states reporting, 11% of complaints (n = 9,315) were against board and care homes. However, not all Ombudsman Programs target board and care homes, although there is increasing interest in this area (see Schiman & Lordeman, 1989a). Overall, states reported low percentages of complaints against regulatory or reimbursement agencies: from 0% in 7 states to 25% (n = 439) in Minnesota. For those states reporting, 3% of complaints (n = 3,067) were against regulatory or reimbursement agencies. Finally, AoA requests the percentage of total complaints concerning others (e.g., guardians, family, any other). Of those states reporting, percentages ranged from 0% in Delaware to 42% in Alaska (/? = 107). Numbers ranged from 0 in Delaware to 900 complaints in Massachusetts. An average 7% of complaints were lodged in this last category, representing 5,880 across states. Although the majority of states complete the AoArecommended forms, 27 states (AR, AZ, CA, CO, CT, DC, FL, ID, IA, KS, LA, MA, ME, M l , MN, NH, NJ, NY, OH, OK, PA, Rl, TN, VA, VT, WA, and Wl) sent the authors copies of state-level activity reports that included more information than is required by AoA. Reports varied greatly in length, content, and format. Each report was analyzed according to the data elements reported and the issues identified. Of those 27 states forwarding more comprehensive state-level reports, 20 contained statistical data. Data elements that went beyond the AoA reporting requirements included complaint referral source, al-
Resolution of Complaints AoA reporting forms include three complaint resolution categories: (1) resolved or partially resolved, (2) not acted upon (withdrawn or not resolved), and (3) still active at end of federal fiscal year. If the complaint is resolved or partially resolved, the problem was corrected or partially corrected to the satisfaction of the resident. Percentage of complaints that were resolved or partially resolved ranged from 97% in Alaska (n = 459) to 35% in Washington (n = 1,145). Numbers of complaints in this category ranged from 4,849 in New York to 150 in Hawaii. The percentage of complaints that were not acted upon (e.g., either withdrawn or not resolved) ranged from 51% (n = 2,057) in Pennsylvania to 0% in Alaska and New jersey. Numbers of complaints not acted upon ranged from 6,712 in Kansas to 0 in Alaska and New Jersey. Total complaints that were still active at year's end ranged from 79% (n = 581) in New Hampshire to 0% in Arizona, Maryland, Michigan, Minnesota, Mississippi, New York, Tennessee, and Vermont. Nationally, the number of complaints resolved or partially resolved was 61,019 (66%), number of complaints not acted upon was 20,091 (22%), and number of comVol. 32, No. 6,1992
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plaints remaining active at year's end was 12,049 (13%). Some aggregate data are available that can be examined together: staffing patterns (Schiman & Lordeman, 1989a) and percentage of complaints resolved (Kusserow, 1991). Schiman and Lordeman (1989a) published Ombudsman Program staffing patterns reported to NASUA in 1987. The percentage of ombudsman staff members who are volunteers ranged from 0% in 13 states to 99% in Oregon and Texas. The nationwide mean is 56%; over half of Ombudsman Program workers are not paid. Relationships between complaint categories and staffing patterns are reported elsewhere (Huber, Netting, & Paton, 1991).
Discussion States vary greatly in the comprehensiveness of their reporting systems. Some states collect complaints by subcategory, but AoA does not request specificity beyond the 9 general categories of complaints depicted in Figure 1. States such as Georgia computerize their data collection efforts; others hand tabulate. A number of states develop annual reports that provide data and issues beyond AoArequested information. Whereas some substate units use standardized collection tools, others leave reporting to individual substate units. Generally, substate units aggregate complaints and forward
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Table 2. Issues Identified in State Ombudsman Reports, As Reported by States in 1990
Number of states identifying issue
Issue Quality of care Elder abuse Staff shortages in nursing homes Physical/chemical restraints Nursing home regulation/enforcement Long-term care financing Medicaid discrimination Boarding care supplements Personal needs allowance Medical assistance Ombudsman access Caps in continuum of care Transfer Mental health service needs Guardianship Ombudsman expansion and funding Alzheimer's/dementia Nurse's aide training Legal assistance needs Younger residents in facilities Staff qualifications in long-term care Personal property loss Bed hold payment Circuit breaker Standardization of data collection Lack of prevention Access to care Living wills Smoking Staff shortage in governmental agencies Aids Ethical decision making Coordination between ombudsman and health units
8 7 7 6 6 4 4 4 4 3 3 3
3 2 2
3 2 2 2 2 2 2 1 1 1 1
1 1 1 1 1 1 1
these figures to state units on aging. State units aggregate complaints across substate units, and AoA receives aggregated data that they again aggregate into gross numbers of national complaints. Results indicate that 38,128 complaints fell in the "resident care" category alone. The reliability of these data is difficult to determine given the variation among states and, within states, among substate units. It is unlikely that volunteers and paid staff are trained in a standardized fashion to distinguish among complaint categories; thus, interrater reliability is questionable at best. In addition, one cannot distinguish between inquiries that are easily cleared up and formal complaints that require lengthly negotiation. Possibly, the 38,128 resident care complaints represent a combination of inquiries and complaints, leading to an inflated number of complaints. AoA's form requests that complaint investigators be identified as (1) ombudsman staff alone, (2) state agencies alone, or (3) joint investigation. Unfortunately, ombudsman staff are not distinguished by paid or volunteer status. It is likely that more difficult or controversial complaints may be handled by paid staff, but reports do not allow one to verify this The Gerontologist
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though codes used to report referral source varied. For example, California listed 13 referral sources (unknown contact, patient/resident, relative, ombudsman, facility administrator, other facility staff, acute hospital staff, physician, lawyer, friend of resident, area agency/l&R, other government agencies, and other). New York, by contrast, listed five (resident, ombudsman, relative/friend, facility staff, and other). Other descriptive data elements that reflected contact with other agencies and consumers included information and referral contacts, hotline or consultation calls, and state regulatory agency referrals. Surprisingly few states report data on the elderly persons for whom the ombudsman service is provided, for example, the age, ethnicity, gender, or other demographic characteristics. Eight states go beyond what is reported on the AoArecommended form and provide cross-tabulation tables. Although reporting categories are fairly standardized, there are variations in facility types. For example, Vermont divides facility type dichotomously (nursing homes and residential care homes), whereas Arizona breaks down facilities by seven types (unlicensed homes; nursing homes; registered care and foster care homes; self or family members; supervisory care homes; guardian or developmental disability facility; and regulatory or reimbursement agency). Five states break down their complaint statistics by substate or district level. Two states provide detailed statistical tables cross-tabulating AoA complaint categories by resolution as well as by facility type. These data elements reflect state-level annual reports submitted to the authors. Although several states forwarded copies of state and substate reporting forms used in their respective areas, all data elements collected were not always reported in annual state reports. In fact, it appeared that substate units in some states collect information that is not reported to their state units on aging. Similarly, not all data elements collected at the state level are always reported to AoA. In a content analysis of state reports, 33 issues were identified by state ombudspersons as areas for recommended change (see Table 2). The list includes such disparate issues as care financing, elder abuse, and living wills.
We did not find a systematic evaluation of the ombudsman program at the national level conducted within the last ten years. We interviewed AoA officials, who told us that the agency has not conducted an impact evaluation of the ombudsman program, nor has it defined what should constitute the impact of the program. (Chelimsky, 1991, p. 18) The General Accounting Office went on to identify Vol.32, No. 6,1992
program outcomes specified in the Older Americans Act and those factors likely to influence impact: (1) ombudsman staff training, (2) development of citizen organizations, (3) ombudsman involvement in regulatory and policy recommendations, (4) ombudsman provision of information to public agencies and others, (5) coordination with the advocacy system for the developmentally disabled and mentally ill, and (6) resident access to ombudsmen. (Chelimsky, 1991, pp. 21-22) It was acknowledged that AoA reporting forms do not address these factors, but that some states collect data in these areas. The testimony also addressed the AoA reporting form, indicating that there are design problems that impede data analysis. For example, there is no way to link complaint category to resolution of complaint. The General Accounting Office recommended that at a minimum AoA would need to modify its data collection form (Chelimsky, 1991). The AoA reporting format reinforces the concerns expressed by the General Accounting Office. Complaint categories are so aggregated that specifics are lost. For example, the resident care category has 29 subcategories that include everything from physical abuse to clothing in poor condition. Those complaints that are reported cannot be analyzed by who investigated them, whether they were resolved, or facility type. Only raw percentages (that do not always add to 100%) are reported. Questions such as "Do ombudsmen work with other agencies to resolve certain types of complaints more than others?" or "Are certain types of complaints more likely resolved than others?" cannot be answered. Indeed, it is what the report cannot tell us that is problematic. For example, we cannot cross-tabulate how complaints were investigated by nature of complaint. Therefore, we do not know if the ombudsmen typically resolves complaints about resident care more frequently than complaints about resident rights. If we knew this information, an appropriate intervention surrounding resident rights could be proposed. We cannot identify regional and/or state differences in numbers of complaints. Therefore, we do not know whether there are high-risk areas in which certain types of problems are likely to occur. We do not have data on source of complaints and, thus, cannot distinguish those from residents themselves, families, friends, staff, or others. We have almost no reported data on the gender, age, socioeconomic status and ethnicity of the program's clientele. AoA could develop and require a more extensive reporting form that standardizes all the data received so that states conform to a minimum data-set requirement, much like nursing homes do with their OBRAinitiated minimum data set assessment system. This is one solution, but it has multiple implications. First, the ownership felt by individual states in developing tailor-made reporting systems could be diminished. There could be a perception that "the feds" are putting more requirements on program staff at a time when resources are already strained, and that this reflects insensitivity to local and state differences. 847
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assumption. Given that most states have multiple agencies that could be involved in complaint investigations, it is unfortunate that no distinctions are made among state agencies. Definition of complaint resolution is equally unsatisfactory. No distinction is made between complaints that are resolved and those that are partially resolved. Complaint resolution categories are not mutually exclusive. For example, partially resolved complaints could also still be active at year's end. More important, however, is the unanswered question regarding whose resolution is sought. To whose satisfaction are complaints resolved and are older residents satisfied with resolutions achieved? Targets of complaints could reveal how active ombudsman programs are in addressing the needs of both skilled care and board and care home residents. Again, however, the data are relatively meaningless given that one cannot determine how many of these targeted complaints were resolved and what types of complaints were lodged against specific targets. Federal law allows each state to design a reporting system to meet the needs of its various constituencies and to collect data relevant to those needs. What is lost in the ombudsman reporting process is any opportunity for regional and national comparability. State reports vary in what Ombudsman Program activities are reported and in the extensiveness of this information. Since state systems vary substantially, little comparable data exist from which to identify trends, associations, and patterns. In short, the important efforts performed at the local level are not fully heard at the national level. One approach to resolving this dilemma is to standardize the entire reporting system. Instead of a "recommended" AoA reporting form, AoA could require that all states utilize its complaint categories. Our analysis finds that most states do use this recommended format, even though it is not required. Some states attempt to provide additional data or to expand upon the AoA categories in a meaningful way. However, using the current AoA reporting format is problematic. On June 13, 1991 the General Accounting Office presented testimony on the Ombudsman Program to the United States Senate Committee on Labor and Human Resources Subcommittee on Aging, as part of the hearings on reauthorization of the Older Americans Act. Specific to data collection needs, this testimony asked, "What impact can be expected from the program, and what impact data, including information on factors likely to affect impact, are being collected by the Administration on Aging (AoA) and the states?" (Chelimsky, 1991, p. 1). The Assistant Comptroller General testified that:
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adult day, home care, etc.); (8) characteristics of facility (i.e., nonprofit, for-profit, public, urban, rural, etc.); (9) identifier for resident (to capture unduplicated client numbers), (10) characteristics of the resident for whom the complaint was lodged (i.e., age, gender, race/ethnicity, availability of family/significant other, role played, etc.); (11) complaint disposition (i.e., mediation, referral, confrontation, legal intervention, etc.); (12) other agencies involved (i.e., protective services, legal services, health department, etc.); (13) who investigated complaint; (14) complaint resolution (what happened); and (15) date of complaint resolution. If the AoA does not require a minimal amount of information from each state, there is really no need to continue to collect the information that is currently being collected. Although it raises numerous questions, it answers very few. Without major changes in the current reporting system, each state could develop its own system and collect those data relevant to state and local authorities without attempting to provide comparative data for national analyses. The decisions currently being made in the ombudsman reporting system are crucial to persons concerned with long-term care policy in this country. These decisions will influence whether we have information on who is complaining and why. If a meaningful data base can be developed for the Long-Term Care Ombudsman Program, new light will be shed on what is happening in the nation's nursing and board and care homes. Without a meaningful data base, the potential for a national reporting system for this program will be lost.
References Berry, J. T. (1990). Information memorandum AoA-IM-90-14: Report to Congress on long-term care ombudsman activities forFY 1988. Washington, DC: Department of Health and Human Services, Administration on Aging. Chelimsky, E. (1991, June 13). Access to and utilization of the Ombudsman Program under the Older Americans Act. U.S. General Accounting Office Testimony before the Subcommittee on Aging, Senate Committee on Labor and Human Resources. Huber, R., Netting, F. E., & Paton, R. N. (1991). Relationships between staff mix in long-term care ombuds programs and outcomes. Unpublished manuscript. Kusserow, R. P. (1991). Ombudsman output measures: Management advisory report. Washington, DC: Department of Health and Human Services, Office of the Inspector General. Monk, A., Kaye, W. L, & Litwin, H. (1984). Resolving grievances in the nursing home: A study of the Ombudsman Program. New York: Columbia University Press. National Association of State Units on Aging. (1988). Comprehensive analysis of state long-term care ombudsman offices. Washington, DC: Author. Schiman, C , & Lordeman, A. (1989a). A study of the involvement of state long-term care ombudsman programs in board and care issues. Washington, DC: National Center for State Long-Term Care Ombudsman Resources, National Association for State Units on Aging. Schiman, C , & Lordeman, A. (1989b). A study of the use of volunteers by long-term care ombudsman programs: The effectiveness of recruitment, supervision, and retention. Washington, DC: National Center for State Long-Term Care Ombudsman Resources, National Association for State Units on Aging.
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Second, training substate ombudspersons and their representatives to complete standardized tools begs the question of interrater reliability. It would take time, funding, and effort to be certain that definitions are operationalized and that ombudsman staff (often volunteers) are interpreting concepts and completing forms in the same manner. Some staff and volunteers, in the face of this increasing standardization may perceive the program as becoming more bureaucratic. Special efforts will be needed to make sure that ombudspersons see the value of this data collection process. Third, without adequate knowledge to know what is appropriate to gather, standardized forms could wind up collecting data that is basically not relevant to a better understanding of the Ombudsman Program nationwide. What, for example, does the Congress want to know about how the Ombudsman Programs work with protection and advocacy systems? Fourth, and extremely important, is how the data will be analyzed. AoA has its own resource limitations. Setting up a meaningful data base on the Ombudsman Program requires having the resources to collect, verify, code, analyze, and report what is forwarded from state programs. It appears that the Ombudsman Program poses a basic dilemma. The federal government has mandated it in each state but allocated minimal resources. The intent of this social policy is to provide a mechanism whereby the complaints of frail elderly can be heard. Anecdotally, there are many success stories. However, there is minimal accountability. Based on the recommendations of the General Accounting Office, in Fall 1991 the Administration on Aging began engaging ombudsman programs in a process of discussing what data need to be collected. We suggest that only those data elements necessary to measure program outputs and outcomes should be collected by AoA, that state and local programs need to influence what those outputs and outcomes are, and that we are at a critical crossroad. We have an opportunity for practitioners, researchers, and policymakers to work together to design an ombudsman data base that could provide meaningful data on resident concerns and complaints. We further suggest that any new reporting system provide clear instructions regarding when complaint forms are to be completed. Understanding when an inquiry becomes a complaint is crucial. Otherwise all inquiries will be perceived as complaints, even when they are resolved easily via phone or visit. The complaint form should include at a minimum the following data elements: (1) identifier for the ombudsperson completing the form; (2) paid or volunteer status (see Schiman & Lordeman, 1989b); (3) date complaint was initiated; (4) complaint category and subcategory; (5) brief description of complaint; (6) source of complaint (who lodged complaint); (7) facility type (i.e., nursing home, board and care,
Using paid staff and/or volunteers, long-term care ombudsman programs are charged with resolving complaints and solving problems that affect elderly persons in a variety of long-term care settings. This paper reports the results of a content analysis of annual ombudsman program reports sent to the Administration on Aging from 49 states in 1990. We found substantial variation in the documented information at both state and local levels and recommend revising the reporting system. Key Words: Data collection, Long-term care, Ombudsman
F. Ellen Netting, PhD,2 Ruth Nelson Paton, PhD,3 and Ruth Huber, PhD3
findings regarding the types of problems . . . of individuals residing in long term care facilities, and to provide policy, regulatory, and legislative recommendations to such problems, resolve such complaints, and improve the quality of care and life in long term care facilities. (NASUA, 1988, p. 37)
The Long-Term Care Ombudsman Program is mandated through Section 307(a) (12) of the Older Americans Act (OAA). State agencies on aging are required to establish and operate either directly, through contract, or other arrangement an Office of the State Ombudsman. This office is responsible for investigating and resolving the complaints of long-term care residents, developing protocols for the ombudsman's access to facility and patient records, establishing a statewide reporting system, assuring client confidentiality, monitoring public long-term care regulations and policies, and providing information on problems affecting older persons in longterm care (Berry, 1990). There are 578 substate Ombudsman programs nationally (Berry, 1990). Flexibility in ombudsman program design is encouraged by the Administration on Aging (AoA) so that appropriate models emerge in different state and substate programs. The literature indicates that models used in different states vary by structure, approach, and staffing (Berry, 1990; Monk, Kaye, & Litwin, 1984; National Association of State Units on Aging, 1988). However, all states are required to
Amendments to the OAA have increasingly strengthened the role of the Long-Term Care Ombudsman Program. The 1991 reauthorization of the act will continue this trend, seeking to increase coordination between ombudsman services, legal assistance programs, and protection and advocacy programs. Federal policymakers are increasingly relying on the Ombudsman Program to provide a community presence for residents in both nursing and board and care homes. This reliance is reflected in the OBRA 1987 Nursing Home Reform Act amendments that require that nursing home residents have direct and immediate access to ombudspersons when protection and advocacy services become necessary. It is also reflected in the 1991 Roybal Board and Care Reform Act, now in Congressional Committee, which requires notification of ombudspersons when facilities are not compliant with the Act's provisions. The requirement that each state develop a statewide complaint reporting system is significant because ombudspersons are increasingly involved in the oversight of both nursing and board and care homes. They are also important sources of information and referral in the aging network. Documentation of what happens in their interactions with residents and other state agencies has implications for program and policy development. The ombudsman complaint data base could provide practitioners, researchers, and policymakers with valuable information on resident concerns. In this paper we report the results of a year-long study of reports to AoA and state-level complaint
submit data on complaints and conditions to the Administration on Aging and to the state licensing or certifying agency on a regular basis. The 1987 Amendments to the Older Americans Act pertaining to the Ombudsman Program added further reporting requirements. These include: preparing an annual report containing data and 1 Special appreciation goes to Tina Liu for her valuable assistance in this research. The authors especially thank Elma Holder, Barbara Frank, and Sara Burger from NCCNHR; Cathy Schiman from NASUA; William F. Benson from the Senate Committee on Labor and Human Resources Subcommittee on Aging; and Sue Wheaton at the Administration on Aging for their advice and support during this project. ^Associate professor, Arizona State University School of Social Work, Tempe,AZ 85251-1802. 'Assistant professor, Kent School of Social Work, University of Louisville, Louisville, KY.
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The Long-Term Care Ombudsman Program: What Does the Complaint Reporting System Tell Us?1
reports by state ombudsman programs to determine what the current reporting system tells us. Methods
Results
Because state programs publish their reports according to varying fiscal years, the data reported in this paper reflect the most recent report issued by individual states as of May 1991. These data reflect complaints and activities for state ombudsman programs during the 1989-1990 fiscal year. In 1990, 49 states were using the AoA reporting categories to categorize complaints, but states varied in how they utilized these categories and subcategories. For example, Connecticut breaks out 603 abuse complaints under resident care so that these complaints will not be subsumed under one broad category. Other states provide a more detailed overview of complaint reporting. A total of 134,612 complaints were reported by 49 states and the District of Columbia. The largest complaint category was resident care, with a total of 38,128 complaints reported. Resident care encompasses 29 subcategories including all aspects of abuse and neglect. Examples of subcategories under resident care are inadequate hygiene care, not dressed, physical abuse, and neglect (see Figure 1). Fewer states (42) used the remainder of the AoArecommended reporting form, which requests (1) the percentages of complaints investigated by ombuds-
Resident care
Table 1. Ombudsman Program Complaint Categories on AoA-Recommended Reporting Form
38.1
Physician services ' • 2.9
A. Resident Care (29 subcategories including items such as not dressed, physical abuse, neglect, staff poorly trained, inadequate care plan, and clothing in poor condition) B. Physician Services (7 subcategories including items such as schedule of visits and not responsive in emergency) C. Medications (6 subcategories including items such as not given according to orders and oversedation) D. Financial (9 subcategories including items such as bill/accounting wrong or denied, and questionable . charges by facility) E. Food/Nutrition (15 subcategories including such items as cold, not assisted in eating, no water available, and unsanitary) F. Administrative (15 subcategories including such items as understaffing, roommate conflict, and laundry procedures) G. Resident Rights (26 subcategories including such items as no grievance procedures, denied rights, and violation of privacy) H. Building, Sanitation, Laundry (16 subcategories including such items as cleanliness, pests, and lighting) I. Not Against Facility (13 subcategories including such items as Medicaid reclassification, Medicare, and family problems)
Medications ~~H 4 Financial ~ ^ | 4.9 Food/nutrition Administration Resident rights Building Not against facility
18.7 0
10
20
30
40
50
(In Thousands) Figure 1. Number of ombudsman complaints nationwide by AoA categories (1990).
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In conversations with staff at the National Association of State Units on Aging (NASUA) and the National Citizens Coalition for Nursing Home Reform (NCCNHR), who jointly direct the AoA-funded National Aging Resource Center on the Long-Term Care Ombudsman Program, and with ombudspersons at both the state and substate levels, we learned that states were very diverse in how they collected, analyzed, and reported data on complaints received by state and substate ombudspersons. Some states developed very elaborate annual reports, whereas others penciled in their reports on AoA-recommended reporting forms and some states did not use AoA reporting forms at all. The recommended form contains 136 complaint types organized into 9 categories. Although the AoA form provides space for reporting totals in each category, there are numerous subcategories. Table 1 lists the AoA complaint categories and the number of subcategories for each. In August 1990 we wrote a letter to all state ombudsman programs, specifically requesting copies of their (1) most recent state-level annual report, (2) AoA report, and (3) state-level forms used to document ombudsman complaints and activities. After two follow-up letters were mailed, a research assistant began telephone follow-ups in November. Some states were called as many as five times. By May 1991, all but one state had responded. A systematic content analysis of these reports was conducted. AoA complaint categories were analyzed first. Some states expanded the complaint categories
on the AoA form, whereas a few integrated the AoA categories into more elaborate annual reports. Over half the states (27) reported more information than was required by AoA. Data elements collected by each state were extracted in order to identify patterns across states. Narrative was content-analyzed to identify themes and issues across state-level reports.
person staff and/or other agencies; (2) resolution of complaints; and (3) the percentage of complaints against various types of facilities. Investigation means that an ombudsman volunteer or staff person actually opened a case and took some action to see whether the complaint could be verified. Complaints by Investigators Because the AoA reporting form does not distinguish between paid and volunteer staff, "ombudsman staff" includes both paid personnel and volunteers. Percentage of total complaints investigated by the staff ranged from 100% in Vermont (n = 400) to 20% in Kansas (n = 228). Numbers of complaints investigated by the ombudsman staff ranged from 97 in Alaska to 7,047 in Massachusetts, but it should be noted that Alaska had one full-time staff person, 30 part-time staff, and no volunteers (31 total), whereas Massachusetts had 26 full-time paid staff, 14 parttime staff, and 140 volunteers (180 total) (Schiman & Lordeman, 1989a, p. 25). Obviously, geographical space and population density vary tremendously between these two ends of the continuum. The percentage of total complaints investigated by agencies other than the state unit on aging or area agencies on aging ranged from 80% in Kansas (n = 913) to 0% in Massachusetts, Mississippi, New Jersey, Tennessee, and Vermont. Those complaints jointly investigated by ombudsman staff and other agencies ranged from 60% in Maine to 0% in Georgia and Washington. Nationally, the number of complaints investigated by ombudsman staff alone was 69,023 (78%), by state agencies alone 10,505 (12%), and jointly investigated 9,017 (10%).
Complaint Targets AoA reporting categories for target of complaint are: (1) skilled or intermediate facilities, (2) board and care facilities, (3) regulatory or reimbursement agencies, and (4) others (e.g., guardians, family, and others). The greatest percentage of complaints (79% overall) was lodged against skilled or intermediate nursing facilities, ranging from 98% in Texas (n = 5,301) to 14% in Alaska (n = 36). For the 41 states reporting on target categories, 69,949 complaints were against skilled or intermediate nursing facilities. Complaints against board and care facilities ranged from 41% (n = 599) in Arizona to 0% in Illinois, Nebraska, and Texas. For the 41 states reporting, 11% of complaints (n = 9,315) were against board and care homes. However, not all Ombudsman Programs target board and care homes, although there is increasing interest in this area (see Schiman & Lordeman, 1989a). Overall, states reported low percentages of complaints against regulatory or reimbursement agencies: from 0% in 7 states to 25% (n = 439) in Minnesota. For those states reporting, 3% of complaints (n = 3,067) were against regulatory or reimbursement agencies. Finally, AoA requests the percentage of total complaints concerning others (e.g., guardians, family, any other). Of those states reporting, percentages ranged from 0% in Delaware to 42% in Alaska (/? = 107). Numbers ranged from 0 in Delaware to 900 complaints in Massachusetts. An average 7% of complaints were lodged in this last category, representing 5,880 across states. Although the majority of states complete the AoArecommended forms, 27 states (AR, AZ, CA, CO, CT, DC, FL, ID, IA, KS, LA, MA, ME, M l , MN, NH, NJ, NY, OH, OK, PA, Rl, TN, VA, VT, WA, and Wl) sent the authors copies of state-level activity reports that included more information than is required by AoA. Reports varied greatly in length, content, and format. Each report was analyzed according to the data elements reported and the issues identified. Of those 27 states forwarding more comprehensive state-level reports, 20 contained statistical data. Data elements that went beyond the AoA reporting requirements included complaint referral source, al-
Resolution of Complaints AoA reporting forms include three complaint resolution categories: (1) resolved or partially resolved, (2) not acted upon (withdrawn or not resolved), and (3) still active at end of federal fiscal year. If the complaint is resolved or partially resolved, the problem was corrected or partially corrected to the satisfaction of the resident. Percentage of complaints that were resolved or partially resolved ranged from 97% in Alaska (n = 459) to 35% in Washington (n = 1,145). Numbers of complaints in this category ranged from 4,849 in New York to 150 in Hawaii. The percentage of complaints that were not acted upon (e.g., either withdrawn or not resolved) ranged from 51% (n = 2,057) in Pennsylvania to 0% in Alaska and New jersey. Numbers of complaints not acted upon ranged from 6,712 in Kansas to 0 in Alaska and New Jersey. Total complaints that were still active at year's end ranged from 79% (n = 581) in New Hampshire to 0% in Arizona, Maryland, Michigan, Minnesota, Mississippi, New York, Tennessee, and Vermont. Nationally, the number of complaints resolved or partially resolved was 61,019 (66%), number of complaints not acted upon was 20,091 (22%), and number of comVol. 32, No. 6,1992
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plaints remaining active at year's end was 12,049 (13%). Some aggregate data are available that can be examined together: staffing patterns (Schiman & Lordeman, 1989a) and percentage of complaints resolved (Kusserow, 1991). Schiman and Lordeman (1989a) published Ombudsman Program staffing patterns reported to NASUA in 1987. The percentage of ombudsman staff members who are volunteers ranged from 0% in 13 states to 99% in Oregon and Texas. The nationwide mean is 56%; over half of Ombudsman Program workers are not paid. Relationships between complaint categories and staffing patterns are reported elsewhere (Huber, Netting, & Paton, 1991).
Discussion States vary greatly in the comprehensiveness of their reporting systems. Some states collect complaints by subcategory, but AoA does not request specificity beyond the 9 general categories of complaints depicted in Figure 1. States such as Georgia computerize their data collection efforts; others hand tabulate. A number of states develop annual reports that provide data and issues beyond AoArequested information. Whereas some substate units use standardized collection tools, others leave reporting to individual substate units. Generally, substate units aggregate complaints and forward
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Table 2. Issues Identified in State Ombudsman Reports, As Reported by States in 1990
Number of states identifying issue
Issue Quality of care Elder abuse Staff shortages in nursing homes Physical/chemical restraints Nursing home regulation/enforcement Long-term care financing Medicaid discrimination Boarding care supplements Personal needs allowance Medical assistance Ombudsman access Caps in continuum of care Transfer Mental health service needs Guardianship Ombudsman expansion and funding Alzheimer's/dementia Nurse's aide training Legal assistance needs Younger residents in facilities Staff qualifications in long-term care Personal property loss Bed hold payment Circuit breaker Standardization of data collection Lack of prevention Access to care Living wills Smoking Staff shortage in governmental agencies Aids Ethical decision making Coordination between ombudsman and health units
8 7 7 6 6 4 4 4 4 3 3 3
3 2 2
3 2 2 2 2 2 2 1 1 1 1
1 1 1 1 1 1 1
these figures to state units on aging. State units aggregate complaints across substate units, and AoA receives aggregated data that they again aggregate into gross numbers of national complaints. Results indicate that 38,128 complaints fell in the "resident care" category alone. The reliability of these data is difficult to determine given the variation among states and, within states, among substate units. It is unlikely that volunteers and paid staff are trained in a standardized fashion to distinguish among complaint categories; thus, interrater reliability is questionable at best. In addition, one cannot distinguish between inquiries that are easily cleared up and formal complaints that require lengthly negotiation. Possibly, the 38,128 resident care complaints represent a combination of inquiries and complaints, leading to an inflated number of complaints. AoA's form requests that complaint investigators be identified as (1) ombudsman staff alone, (2) state agencies alone, or (3) joint investigation. Unfortunately, ombudsman staff are not distinguished by paid or volunteer status. It is likely that more difficult or controversial complaints may be handled by paid staff, but reports do not allow one to verify this The Gerontologist
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though codes used to report referral source varied. For example, California listed 13 referral sources (unknown contact, patient/resident, relative, ombudsman, facility administrator, other facility staff, acute hospital staff, physician, lawyer, friend of resident, area agency/l&R, other government agencies, and other). New York, by contrast, listed five (resident, ombudsman, relative/friend, facility staff, and other). Other descriptive data elements that reflected contact with other agencies and consumers included information and referral contacts, hotline or consultation calls, and state regulatory agency referrals. Surprisingly few states report data on the elderly persons for whom the ombudsman service is provided, for example, the age, ethnicity, gender, or other demographic characteristics. Eight states go beyond what is reported on the AoArecommended form and provide cross-tabulation tables. Although reporting categories are fairly standardized, there are variations in facility types. For example, Vermont divides facility type dichotomously (nursing homes and residential care homes), whereas Arizona breaks down facilities by seven types (unlicensed homes; nursing homes; registered care and foster care homes; self or family members; supervisory care homes; guardian or developmental disability facility; and regulatory or reimbursement agency). Five states break down their complaint statistics by substate or district level. Two states provide detailed statistical tables cross-tabulating AoA complaint categories by resolution as well as by facility type. These data elements reflect state-level annual reports submitted to the authors. Although several states forwarded copies of state and substate reporting forms used in their respective areas, all data elements collected were not always reported in annual state reports. In fact, it appeared that substate units in some states collect information that is not reported to their state units on aging. Similarly, not all data elements collected at the state level are always reported to AoA. In a content analysis of state reports, 33 issues were identified by state ombudspersons as areas for recommended change (see Table 2). The list includes such disparate issues as care financing, elder abuse, and living wills.
We did not find a systematic evaluation of the ombudsman program at the national level conducted within the last ten years. We interviewed AoA officials, who told us that the agency has not conducted an impact evaluation of the ombudsman program, nor has it defined what should constitute the impact of the program. (Chelimsky, 1991, p. 18) The General Accounting Office went on to identify Vol.32, No. 6,1992
program outcomes specified in the Older Americans Act and those factors likely to influence impact: (1) ombudsman staff training, (2) development of citizen organizations, (3) ombudsman involvement in regulatory and policy recommendations, (4) ombudsman provision of information to public agencies and others, (5) coordination with the advocacy system for the developmentally disabled and mentally ill, and (6) resident access to ombudsmen. (Chelimsky, 1991, pp. 21-22) It was acknowledged that AoA reporting forms do not address these factors, but that some states collect data in these areas. The testimony also addressed the AoA reporting form, indicating that there are design problems that impede data analysis. For example, there is no way to link complaint category to resolution of complaint. The General Accounting Office recommended that at a minimum AoA would need to modify its data collection form (Chelimsky, 1991). The AoA reporting format reinforces the concerns expressed by the General Accounting Office. Complaint categories are so aggregated that specifics are lost. For example, the resident care category has 29 subcategories that include everything from physical abuse to clothing in poor condition. Those complaints that are reported cannot be analyzed by who investigated them, whether they were resolved, or facility type. Only raw percentages (that do not always add to 100%) are reported. Questions such as "Do ombudsmen work with other agencies to resolve certain types of complaints more than others?" or "Are certain types of complaints more likely resolved than others?" cannot be answered. Indeed, it is what the report cannot tell us that is problematic. For example, we cannot cross-tabulate how complaints were investigated by nature of complaint. Therefore, we do not know if the ombudsmen typically resolves complaints about resident care more frequently than complaints about resident rights. If we knew this information, an appropriate intervention surrounding resident rights could be proposed. We cannot identify regional and/or state differences in numbers of complaints. Therefore, we do not know whether there are high-risk areas in which certain types of problems are likely to occur. We do not have data on source of complaints and, thus, cannot distinguish those from residents themselves, families, friends, staff, or others. We have almost no reported data on the gender, age, socioeconomic status and ethnicity of the program's clientele. AoA could develop and require a more extensive reporting form that standardizes all the data received so that states conform to a minimum data-set requirement, much like nursing homes do with their OBRAinitiated minimum data set assessment system. This is one solution, but it has multiple implications. First, the ownership felt by individual states in developing tailor-made reporting systems could be diminished. There could be a perception that "the feds" are putting more requirements on program staff at a time when resources are already strained, and that this reflects insensitivity to local and state differences. 847
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assumption. Given that most states have multiple agencies that could be involved in complaint investigations, it is unfortunate that no distinctions are made among state agencies. Definition of complaint resolution is equally unsatisfactory. No distinction is made between complaints that are resolved and those that are partially resolved. Complaint resolution categories are not mutually exclusive. For example, partially resolved complaints could also still be active at year's end. More important, however, is the unanswered question regarding whose resolution is sought. To whose satisfaction are complaints resolved and are older residents satisfied with resolutions achieved? Targets of complaints could reveal how active ombudsman programs are in addressing the needs of both skilled care and board and care home residents. Again, however, the data are relatively meaningless given that one cannot determine how many of these targeted complaints were resolved and what types of complaints were lodged against specific targets. Federal law allows each state to design a reporting system to meet the needs of its various constituencies and to collect data relevant to those needs. What is lost in the ombudsman reporting process is any opportunity for regional and national comparability. State reports vary in what Ombudsman Program activities are reported and in the extensiveness of this information. Since state systems vary substantially, little comparable data exist from which to identify trends, associations, and patterns. In short, the important efforts performed at the local level are not fully heard at the national level. One approach to resolving this dilemma is to standardize the entire reporting system. Instead of a "recommended" AoA reporting form, AoA could require that all states utilize its complaint categories. Our analysis finds that most states do use this recommended format, even though it is not required. Some states attempt to provide additional data or to expand upon the AoA categories in a meaningful way. However, using the current AoA reporting format is problematic. On June 13, 1991 the General Accounting Office presented testimony on the Ombudsman Program to the United States Senate Committee on Labor and Human Resources Subcommittee on Aging, as part of the hearings on reauthorization of the Older Americans Act. Specific to data collection needs, this testimony asked, "What impact can be expected from the program, and what impact data, including information on factors likely to affect impact, are being collected by the Administration on Aging (AoA) and the states?" (Chelimsky, 1991, p. 1). The Assistant Comptroller General testified that:
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adult day, home care, etc.); (8) characteristics of facility (i.e., nonprofit, for-profit, public, urban, rural, etc.); (9) identifier for resident (to capture unduplicated client numbers), (10) characteristics of the resident for whom the complaint was lodged (i.e., age, gender, race/ethnicity, availability of family/significant other, role played, etc.); (11) complaint disposition (i.e., mediation, referral, confrontation, legal intervention, etc.); (12) other agencies involved (i.e., protective services, legal services, health department, etc.); (13) who investigated complaint; (14) complaint resolution (what happened); and (15) date of complaint resolution. If the AoA does not require a minimal amount of information from each state, there is really no need to continue to collect the information that is currently being collected. Although it raises numerous questions, it answers very few. Without major changes in the current reporting system, each state could develop its own system and collect those data relevant to state and local authorities without attempting to provide comparative data for national analyses. The decisions currently being made in the ombudsman reporting system are crucial to persons concerned with long-term care policy in this country. These decisions will influence whether we have information on who is complaining and why. If a meaningful data base can be developed for the Long-Term Care Ombudsman Program, new light will be shed on what is happening in the nation's nursing and board and care homes. Without a meaningful data base, the potential for a national reporting system for this program will be lost.
References Berry, J. T. (1990). Information memorandum AoA-IM-90-14: Report to Congress on long-term care ombudsman activities forFY 1988. Washington, DC: Department of Health and Human Services, Administration on Aging. Chelimsky, E. (1991, June 13). Access to and utilization of the Ombudsman Program under the Older Americans Act. U.S. General Accounting Office Testimony before the Subcommittee on Aging, Senate Committee on Labor and Human Resources. Huber, R., Netting, F. E., & Paton, R. N. (1991). Relationships between staff mix in long-term care ombuds programs and outcomes. Unpublished manuscript. Kusserow, R. P. (1991). Ombudsman output measures: Management advisory report. Washington, DC: Department of Health and Human Services, Office of the Inspector General. Monk, A., Kaye, W. L, & Litwin, H. (1984). Resolving grievances in the nursing home: A study of the Ombudsman Program. New York: Columbia University Press. National Association of State Units on Aging. (1988). Comprehensive analysis of state long-term care ombudsman offices. Washington, DC: Author. Schiman, C , & Lordeman, A. (1989a). A study of the involvement of state long-term care ombudsman programs in board and care issues. Washington, DC: National Center for State Long-Term Care Ombudsman Resources, National Association for State Units on Aging. Schiman, C , & Lordeman, A. (1989b). A study of the use of volunteers by long-term care ombudsman programs: The effectiveness of recruitment, supervision, and retention. Washington, DC: National Center for State Long-Term Care Ombudsman Resources, National Association for State Units on Aging.
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Second, training substate ombudspersons and their representatives to complete standardized tools begs the question of interrater reliability. It would take time, funding, and effort to be certain that definitions are operationalized and that ombudsman staff (often volunteers) are interpreting concepts and completing forms in the same manner. Some staff and volunteers, in the face of this increasing standardization may perceive the program as becoming more bureaucratic. Special efforts will be needed to make sure that ombudspersons see the value of this data collection process. Third, without adequate knowledge to know what is appropriate to gather, standardized forms could wind up collecting data that is basically not relevant to a better understanding of the Ombudsman Program nationwide. What, for example, does the Congress want to know about how the Ombudsman Programs work with protection and advocacy systems? Fourth, and extremely important, is how the data will be analyzed. AoA has its own resource limitations. Setting up a meaningful data base on the Ombudsman Program requires having the resources to collect, verify, code, analyze, and report what is forwarded from state programs. It appears that the Ombudsman Program poses a basic dilemma. The federal government has mandated it in each state but allocated minimal resources. The intent of this social policy is to provide a mechanism whereby the complaints of frail elderly can be heard. Anecdotally, there are many success stories. However, there is minimal accountability. Based on the recommendations of the General Accounting Office, in Fall 1991 the Administration on Aging began engaging ombudsman programs in a process of discussing what data need to be collected. We suggest that only those data elements necessary to measure program outputs and outcomes should be collected by AoA, that state and local programs need to influence what those outputs and outcomes are, and that we are at a critical crossroad. We have an opportunity for practitioners, researchers, and policymakers to work together to design an ombudsman data base that could provide meaningful data on resident concerns and complaints. We further suggest that any new reporting system provide clear instructions regarding when complaint forms are to be completed. Understanding when an inquiry becomes a complaint is crucial. Otherwise all inquiries will be perceived as complaints, even when they are resolved easily via phone or visit. The complaint form should include at a minimum the following data elements: (1) identifier for the ombudsperson completing the form; (2) paid or volunteer status (see Schiman & Lordeman, 1989b); (3) date complaint was initiated; (4) complaint category and subcategory; (5) brief description of complaint; (6) source of complaint (who lodged complaint); (7) facility type (i.e., nursing home, board and care,
