Tribal Ombudsman Program in Arizona: A Case Study

HEALTH CARE AND HUMAN SERVICES POLICY, RESEARCH, AND ANALYTICS ― WITH REAL-WORLD PERSPECTIVE.

Prepared for: Administration for Community Living

Submitted by: The Lewin Group

April 27, 2020
1

I. Introduction

The Long-Term Care Ombudsman Program (Ombudsman program) serves individuals living in 

long-term care facilities, such as nursing homes, board and care, assisted living, and other 

residential care facilities, and works to resolve problems related to the health, safety, welfare, and 

rights of residents in these facilities. The Ombudsman program serves all individuals who reside in 

long-term care facilities, regardless of nationality, race, ethnicity, or other characteristics. The 

Administration for Community Living (ACL), which administers the Ombudsman program at the 

federal level, sought to identify successful practices and generate recommendations for improving 

how Ombudsman programs across the U.S. serve Native populations. In 2019, ACL requested that 

The Lewin Group (Lewin), as a subcontractor to New Editions Consulting, conduct a case study of 

the Tribal Ombudsman program within the Inter Tribal Council of Arizona (ITCA).

II. Background

A. Federal Long-Term Care Ombudsman Program

The Ombudsman program began in 1972 as a demonstration and currently operates in all states, 

the District of Columbia, Puerto Rico, and Guam. Title VII of the Older Americans Act authorizes 

and requires Ombudsman programs to:

· Identify, investigate, and resolve complaints made by or on behalf of residents;

· Provide information to residents about LTSS;

· Ensure that residents have regular and timely access to Ombudsman services;

· Represent the interests of residents before governmental agencies and seek administrative, 

legal, and other remedies to protect residents; and,

· Analyze, comment on, and recommend changes in laws and regulations pertaining to the 

health, safety, welfare, and rights of residents.1

A full-time Ombudsman heads an Office of the State Long-Term Care Ombudsman (State Office)

in every state or territory and administers the program statewide, including staff and volunteers 

who provide direct services to residents. The Older Americans Act gives states operational 

discretion for administering their Ombudsman program. The State Office may be housed within 

the state unit on aging or contracted to another state agency or non-profit entity. At the local level, 

Ombudsman services may be centralized and delivered statewide through the State Office or may 

be provided by local Ombudsman entities, which are often nonprofit agencies, such as Area 

Agencies on Aging.

Across the U.S. and its territories in 2018, there were 53 State Ombudsmen who manage programs 

consisting of 1,297 full-time equivalent staff, and 6,163 volunteers trained to investigate and 

 

1 Long-Term Care Ombudsman: The Purpose of the Program and How it Works. Retrieved January 27, 2020 from 

https://acl.gov/programs/Protecting-Rights-and-Preventing-Abuse/Long-term-Care-Ombudsman-Program.
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resolve complaints.2 Ombudsman programs promote policies and consumer protections to improve 

long-term services and supports at the facility, local, state, and national levels.

B. Services for American Indians, Alaska Natives, and Native Hawaiians

The Older Americans Act also established programs for Native Americans (Title VI), including 

American Indians, Alaska Natives, and Native Hawaiians, beginning in 1978 with the provision of 

nutrition and supportive services. Title VI provides grants to tribes for nutrition and health 

promotion services, home and community-based services, and family caregiver services. Title III 

of the Older Americans Act provides grants to states for the same services for adults age 60 and 

over, including both Native and non-Native elders. Tribes may use Title VI funds for Ombudsman 

services; the services are to be “substantially in compliance” with provisions of Title III (Section 

614(a)(9) of OAA). Some tribes use funds from both Titles VI and VII to support full-time staff

positions that provide services under both titles.

C. Arizona Long-Term Care Ombudsman Program

Arizona’s Office of the State Long-Term Care Ombudsman is housed in the Division of Aging and 

Adult Services (DAAS), which is within the Department of Economic Security (DES). DES

historically has contracted with eight local agencies to 

serve as designated local Ombudsmen entities. In 

2018, a network of 19 paid staff and 59 volunteer 

Ombudsmen (representatives of the Office) provided 

these services.

3

In this structure, the State Office has 

programmatic oversight, but does not directly employ 

the representatives of the Office. Two of the eight

local agencies focus primarily on serving Arizona’s 

large Native population: ITCA and Navajo Nation. 

Although Navajo Nation has historically had a 

contract with DES to provide Ombudsman services, it

currently does not due to a position vacancy.

There are 22 Tribal Nations located within or 

primarily in the state of Arizona (Exhibit 1).

4

Appendix A presents the relationship between ITCA 

and each of the 22 tribes. With the intent to provide 

more culturally appropriate Ombudsman services on 

tribal lands, the White Mountain Apache Tribe

requested to become a contractor to DES to serve their 

 

2 The National Long-Term Care Ombudsman Resource Center. Retrieved December 15, 2019, from 

http://www.ltcombudsman.org/.

3 AGing, Independence, and Disability (AGID) Program Data Portal. Retrieved February 26, 2020 from 

https://agid.acl.gov/DataGlance/NORS/Trend.aspx?geoids=3&jvar=937&mode=Count&agegroup=0&sex=0&pop=

0&service=0&poverty=0&adl=0&iadl=0.

4

ITCA and Arizona State University (2013). The State of Indiana Country Arizona. Retrieved February 18, 2020 

from https://des.az.gov/sites/default/files/the_state_of_indian_country_arizona.pdf. The Inter Tribal Council of 

Arizona is a cooperative of 21 of the 22 tribes. Navajo Nation is not part of the ITCA.
Tribal Ombudsman Program Case Study

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members beginning in the 1990s.5 This is the first known instance of what is now called the Tribal 

Ombudsman program in Arizona. The White Mountain Apache Tribe Ombudsman also served 

members of the Hopi Tribe. DES later worked with the Tohono O’odham and Pascua Yaqui Tribes 

to designate Ombudsmen for their members. These three tribes (i.e., White Mountain Apache, 

Tohono O’odham, and Pascua Yaqui) now provide Ombudsman services to their members under 

contract with ITCA, which also provides Ombudsman services to members of 18 additional tribes.

D. Inter Tribal Council of Arizona Tribal Ombudsman Program

ITCA is a cooperative of 21 tribes that was established in 1952 for tribal governments within the 

state of Arizona to address common issues with a united voice.6ITCA operates more than 30 

projects to support tribal governments with program planning, research, data collection, and 

evaluation.

ITCA operates Title III, VI, and VII programs under the Older Americans Act on behalf of its 

tribal governments. ITCA operates an Area Agency on Aging, which administers Title III and VII 

programs for 18 tribal governments in Arizona. ITCA also administers the Title VI program on 

behalf of four of those tribal governments. Appendix A provides a list of tribes that form ITCA

and programs ITCA administers.

ITCA operates its local Ombudsman program under contract with DES. Formally, ITCA directly 

serves members of 18 tribes and subcontracts with the White Mountain Apache, Tohono O’odham, 

and Pascua Yaqui Tribes to deliver services to their members. In practice, the ITCA Ombudsman 

program provides Ombudsman services to any tribal member in Arizona, regardless of tribe or 

long-term care facility of residence.7

III. Findings

The following represent findings from qualitative interviews with key stakeholders in Arizona. 

Details about the methodology used to collect the data are presented in Appendix B. The findings 

are organized into the following domains: A) Referrals and Triage; B) Relationships; and, C) Trust 

and Cultural Competence. The findings are followed by a series of recommendations to improve 

collaboration between Ombudsman programs and tribes for the benefit of tribal elders.

A. Referrals and Triage

The referral process for Ombudsman services in Arizona typically begins when a resident concern 

or complaint is first reported to any Ombudsman (i.e., State Office or local Ombudsman). Often, a 

family member or facility staff member will email or call the State Office or a local Ombudsman

program, which typically post or advertise their contact information within long-term care facilities

in the state. If a complaint is received at the State Office, the State Ombudsman will review the 

complaint and refer it to the local Ombudsman serving the geographic area in which the long-term 

care facility is located. If a complaint is received by a local Ombudsman, their office will respond

 

5 Researchers found conflicting information on the origins of the Tribal Ombudsman program. 

6

ITCA. Retrieved January 27, 2020 from https://itcaonline.com/about-itca/. 

7 The Navajo Nation has also traditionally operated an Ombudsman program with a designated Ombudsman under 

contract with DES separate from ITCA. The Ombudsman position for the Navajo Nation is currently vacant.
Tribal Ombudsman Program Case Study

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directly. If the individual is determined to be a tribal member, the state or local Ombudsman will 

typically contact ITCA, which will then transfer the case to the Tribal Ombudsman most suited to 

respond.

During the referral process, identification of a resident as a tribal member occurs inconsistently. 

This is because there is no standard procedure followed or question asked about tribal affiliation at 

the time the complaint is received. Often, determination of tribal status occurs as part of the initial 

conversation when a local Ombudsman responds to the concern or complaint. Thus, it is likely that 

there are complaints handled by local non-tribal Ombudsmen for tribal members because tribal 

identification is never made. In some cases, tribal identification is made, but a Tribal Ombudsman 

is not available. For example, because the Navajo Nation does not currently have an Ombudsman 

due to a staff vacancy, the State Office will often handle the case directly or coordinate with ITCA 

to respond.

ITCA plays an important coordination role for Tribal Ombudsman referrals and triage. All 

interviewees spoke of the casual nature of the operational relationships between the DES, ITCA, 

and individual tribes. ITCA conducts significant outreach through established networks (e.g.,

regular state Ombudsman coordinating calls) to educate other Ombudsmen about the Tribal 

Ombudsman program. These professional collaborations have resulted in an informal network with 

the capacity to pass cases to the Ombudsman best suited to respond, sometimes due to geographic 

necessity, and other times because of the specific tribal affiliation of a resident.

B. Relationships

Interviews revealed that formal and informal relationships 

are at the core of the Tribal Ombudsman program. Formal 

relationships include the primary contractual relationships 

between DES and the ITCA8

and ITCA’s secondary 

contractual relationships with the Tohono O’odham, 

White Mountain Apache, and Pascua Yaqui Tribes. 

Informal relationships supporting the referral and triage 

processes include collaborations among Ombudsmen and 

with other programs (e.g., Area Agencies on Aging, 

Adult Protective Services) across the state.

 

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“I think the other thing that works 

well is that there are Ombudsmen 

that they can refer to. So it’s not 

siloed (sic) as a Tribal Ombudsman 

program...So they can call on the 

[non-tribal] Ombudsman to help them 

out if they can’t get to them. And I 

know one tribe actually has, because 

Casa Grande is closer to Gila River, 

that they’ll send an Ombudsman to 

help Gila River out, where we don’t 

necessarily need to be that point 

person. And then they will 

communicate with our Ombudsman 

here, ‘Hey, I went in and I checked on 

it and this is what happened. Do you 

want me to follow up, or do you want 

to follow up?’”

- ITCA Staff Member

Note that there is an additional contractual relationship between DES and Navajo Nation to operate the 

Ombudsman program for Navajo Nation. However, that position is currently vacant.
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1. Relationships for Referrals and Triage

Given the informal, and sometimes inconsistent, manner in which Tribal Ombudsmen receive 

referrals, interviewees identified strong working relationships as essential to successful referral and 

triage processes. Ombudsmen in Arizona are directed to refer all 

cases involving tribal members to ITCA. ITCA often works

jointly with non-tribal Ombudsmen and other service providers 

around the state, depending on the particular issue or location of 

the resident. A non-tribal Ombudsman may conduct an initial visit 

with a tribal member due to geographic proximity and then 

consult with ITCA about who will follow up with the resident. In 

other cases, through collaboration with other Ombudsmen and 

DES, ITCA will accept a referral for a tribal resident living in the 

jurisdiction of another Ombudsman. This coordination reflects the 

philosophical underpinnings of the Ombudsman program, which 

was intended to be a unified program. In fact, DES representatives 

often remarked that ITCA and the Tribal Ombudsman program 

are simply seen as part of the entire spectrum of Ombudsman 

services provided across the state. Coordination occurs between 

Tribal Ombudsmen and non-tribal Ombudsmen during the referral 

process.

Building relationships with service providers across the state enhances referral networks. 

Coordination with other services offered by the tribes (e.g., services funded by Title III, Title VI,

and tribal funds) occurs naturally in some cases because Tribal Ombudsmen often do not serve in 

the Ombudsman role in a full-time capacity. Rather, some staff have split-funded positions where a 

portion of their time is spent on Ombudsman activities and the remaining time is spent in staff 

roles for these other programs. Staff from ITCA reiterated the importance of these relationships

with other non-tribal agencies and noted that state Area Agency on Aging directors’ meetings 

serve as an important connection point for overall coordination with other Area Agency on Aging

services, such as those offered under Titles III and VI. The educational opportunities to discuss the 

Tribal Ombudsman program with other Area Agencies on Aging are critical components of these 

state director meetings. Similarly, an ITCA staff member discussed the regularly occurring

regional conference call of Ombudsmen in Arizona, which helps build relationships with non-tribal 

Ombudsmen.

An additional referral source to the Tribal Ombudsman program, although less frequent, is Adult 

Protective Services.9

ITCA staff noted that Adult Protective Services, either state or tribal, will 

refer cases to the ITCA Tribal Ombudsman program if they feel that an Ombudsman is needed or 

can assist in a particular resident situation. ITCA staff now attend regular stakeholder meetings to 

discuss how to bridge communication between Adult Protective Services and other programs, 

including the Tribal Ombudsman program.

 

“There have been instances 

where tribal members live 

off of tribal land in long-term 

care facilities, and that’s 

been an issue that we have 

worked on for many years as 

to who then serves that 

individual. If that facility is in 

Maricopa County, is it the 

Area Agency of Maricopa 

County, or is it Inter Tribal 

Council of Arizona? And 

we’ve kind of worked 

together to deal with that. So 

it’s usually the Inter Tribal 

Council of Arizona that will 

take the lead.” 

- DES Staff Member

9

ITCA staff noted that, because Ombudsmen are not mandated reporters in Arizona, they do not make referrals to 

Adult Protective Services without the consent of the resident.
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2. Relationships with Long-Term Care Facilities

Strong relationships with long-term care facilities enable Tribal Ombudsmen to more effectively 

serve residents. One ITCA staff member noted that Tribal Ombudsmen intentionally build strong 

relationships with the staff of long-term care facilities (e.g., aides, personal care attendants, nurses, 

other staff). These relationships facilitate positive interactions and allow for easier access within 

facilities, as well as easier problem resolution. One ITCA staff noted that these relationships are 

deliberately fostered and maintained by the Tribal Ombudsmen themselves: “I think the other thing 

that also helps is that when they do visit the facilities, sometimes they do just go in there to say 

hello [to the staff]...the Ombudsmen have these little gifts to them that say, ‘We’re here if you 

need us. You might not need us today, but this is what we do. And if you ever need us, this is our 

card.’”

3. The Role of ITCA and Arizona DES in Fostering Relationships

Trust is foundational to the Tribal Ombudsmen program. DES can have difficulty fostering this 

trust with tribes due to being a state agency. Regardless of current intention or desire to bridge the 

historical inequities and tensions between tribes and U.S. governmental organizations generally, 

this history creates barriers between DES and its relationships with tribes. ITCA’s relationship with 

the DES facilitates stronger relationships between DES and tribes. One DES staff member noted 

the value of ITCA in building these relationships: “I think one thing that’s really helped... [is]

having Inter Tribal Council of Arizona... [they] ha[ve] been a definite plus for us. I don’t know 

how [trust] would have been if we hadn’t had [ITCA] in place. I think it might have been more 

challenging.” Staff attitudes at DES reflect that the Tribal Ombudsman program is simply an 

additional local Ombudsman, which helps ensure that Tribal Ombudsmen are fully integrated into 

the larger Ombudsman program.

C. Trust and Cultural Competence

Interviewees universally identified the concepts of trust and cultural competence as central to the 

operation of the Tribal Ombudsman program. These concepts are integrally linked for tribal 

members. Due to the historical oppression and infringement on tribal sovereignty by federal, state 

and local governments, all interviewees discussed the importance of this deep trust and cultural 

competence as a fundamental underpinning of the Tribal Ombudsman program. Consistently, 

interviewees noted the program could not exist without everyone within the Tribal Ombudsman

program subscribing to and advocating for these ideals. 
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Interviewees frequently returned to the idea of cultural trust as 

trust built through language, knowledge of cultural traditions, and 

years of relationship building. One DES staff member discussed 

the importance of building this trust over the span of multiple 

visits with long-term care facility residents: “If you have 

somebody of a similar cultural background, similar language...

People that understand the importance of food in the culture. 

They’re going to relate. That’s going to build the trust... It still 

may take a few visits... But it may be impossible for somebody 

without [a similar cultural background and language] to do it.”

While having similar cultural experiences may be helpful, several 

interviewees noted that it was less important for the Tribal 

Ombudsman to be from the exact same tribe as the resident than 

to have the general understanding and respect for cultural 

preferences a member of any tribe can have.

Interviewees also frequently mentioned that many of the 

complaints10 that are received from tribal elders in long-term care facilities are based on cultural 

misunderstandings and can be addressed through culturally-competent solutions. As an example, a 

staff member from ITCA recalled a case where a resident in a long-term care facility was very 

upset that staff were requiring her to sleep in her bed. She often wanted to be on the floor of the 

room, rather than in her bed. The resident had been a basket weaver and had worked sitting on the 

floor and, as a result, felt most comfortable being on the floor. A solution was creatively identified 

and implemented to address this complaint. After the intervention by the Tribal Ombudsman, the 

long-term care facility made an accommodation for this elder to sleep on the floor of her room with 

appropriate pillows and blankets.

IV. Conclusion and Recommendations

The Tribal Ombudsman program was developed in the interest of better serving tribal members 

who were residing in long-term care facilities on and off tribal land. Since the early 1990s, the 

Tribal Ombudsman program has successfully grown into a comprehensive program with informal 

referral procedures, strong relationships, and respect within the community. Cultural trust and 

understanding the cultural preferences and needs of residents are central to the success of the 

program.

The following recommendations are offered as possible pathways for Ombudsman programs and 

tribes to work together more effectively for the benefit of tribal elders.

Recommendation 1: Develop a standard protocol to identify tribal members during the 

initial screening process for Ombudsman services. There is no standard procedure in Arizona to 

identify a resident as a tribal member, either during initial receipt of a complaint or during regular 

visits to facilities. It may strengthen the Arizona system and other Ombudsman programs across 

 

“So sometimes in some of 

the communities, it’s the eye 

contact. You don’t make eye 

contact. You’ll notice that 

you talk to some of the tribal 

members, they’ll 

immediately look down. And 

you know they’re 

immediately looking down, 

you’re not going to make 

them uncomfortable by 

looking at them. So you 

might just quickly look at 

them and talk or talk away 

from them, but you’re still 

talking to them.”

- DES Staff Member

10 Although the researchers obtained basic information about volume of activity by Tribal Ombudsmen, no 

information was received regarding the nature of the complaints/concerns.
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the country to establish a single screening question to identify probable tribal members during 

referral and intake, if the local program is near tribal lands. Alternatively, guidance can be offered 

to Ombudsmen for how to collect this information from other documentation (e.g., if the 

Ombudsman is accessing resident records). Depending on the response to the single screening 

question or other identification, processes can be developed to ensure a seamless referral and

culturally competent services.

Recommendation 2: Collaborate with tribal members to use culturally and linguistically 

appropriate methods to identify, respond to, and report complaints. Nationally, the 

Ombudsman program uses the term complaint to describe the reason an individual or 

representative requests Ombudsman services. Tribal members, because of cultural considerations, 

may articulate complaints instead as concerns or other more culturally-derived concepts. In 

definition, complaints and concerns do not differ; however, ITCA noted that there may be underreporting of Tribal Ombudsman program activities because they were not labeled as complaints. 

To address this issue, the state Ombudsmen and tribal organizations should further investigate the 

true volume of complaints by tribal members. Tribal Ombudsman activities may be more 

numerous than data currently indicate due to potential under-reporting of concerns. State 

Ombudsmen need to ensure National Ombudsman Reporting System (NORS) training for all 

representatives of the State Office, regardless of paid or volunteer status and tribal or non-tribal 

membership. As part of their monitoring of programs, each State Office should ensure that NORS 

data is documented in the program’s data management system.

Recommendation 3: Improve the coordination of Ombudsman services to tribal members in 

areas where coordination does not currently exist and there are high concentrations of tribal 

members. ITCA Ombudsmen and organizational leadership play a prominent role in the 

coordination of Ombudsman services to tribal members within Arizona’s Long-Term Care

Ombudsman program. For example, the designated Ombudsman at ITCA formally and informally 

collaborates with the subcontracted Tribal Ombudsmen, serves as the central referral point for the 

provision of Ombudsman services to tribal members, and participates in statewide Ombudsman 

calls to educate others about the Tribal Ombudsman program. In areas where similar regional 

intertribal organizations exist, state and local Ombudsmen can coordinate with intertribal 

organizations to improve Ombudsman services to tribal members.11 Where intertribal 

organizations do not exist, there may be fewer tribal resources, but state Ombudsman programs 

can seek out individual tribes in their areas. Coordination activities could include:

· Periodic educational sessions where tribal representatives educate Ombudsmen on cultural 

competence, tribal sovereignty, and creative problem solving when working with tribal 

residents of long-term facilities;

· Periodic educational sessions for tribes to learn information about the Ombudsman 

program and increase ability to facilitate referrals to the program (e.g., asking tribal longterm care facility residents if they would like an Ombudsman to visit);

· Increased communication and collaboration between other tribal-based elder services and 

Ombudsman services, such as periodic coordination conference calls or meetings;

 

11 The National Congress of American Indians provides a helpful listing of all regional intertribal organizations 

(http://www.ncai.org/tribal-directory/tribal-organizations).
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· Intentional use of volunteers or staff who represent tribes and are designated as 

representatives of the Office in order to provide Ombudsman services to tribal long-term 

care facility residents;

12 and,

· Development of creative strategies between state Ombudsman programs and tribal 

organizations to consider funding streams, including other Older Americans Act Title 

funds and tribal funds to establish a Tribal Ombudsman program.

Recommendation 4: Revise the toolkit on the National Ombudsman Resource Center 

(NORC) website to support collaboration between Ombudsmen, tribes, and tribal members.

A set of helpful tools exist on NORC’s website. Given greater identification of needs and 

promising practices, ACL and NORC could work with the tribal resource center to revise the 

toolkit to support collaboration between tribes and Ombudsmen. Revised or new tools could 

include cultural competence information, ideas for how to communicate with tribal members, or 

contacts for Indian Health Service centers and clinics.

Recommendation 5: Address conflicts of interest that may arise in tribes that own and 

operate long-term care facilities as well as provide Ombudsman program services. The Older 

Americans Act and the Ombudsman program regulation at 45 CFR 1324.21 require the state unit 

on aging and the state Ombudsman to identify both the organizational and individual conflicts of 

interest that may impact the effectiveness and credibility of the work of the State Office. The 

Ombudsman is to develop policies and procedures to address conflicts of interest. These policies 

and procedures must include mechanisms to identify both organizational and individual conflicts, 

to avoid conflicts when possible, and, where conflicts exist, to identify and remedy or remove. The 

Older Americans Act and the regulation (45 CFR 1324.2) identify a variety of conflicts, including 

some that are prohibited. For example, an individual cannot be employed as an Ombudsman and 

by an organization that operates a long-term care facility, and the Office of the Ombudsman cannot 

contract with an entity that operates a long-term care facility. As Ombudsman programs aim to 

expand services on tribal lands, they will need to clearly identify individual and organizational

conflicts and provide remedies. For example, they could:

· Develop remedies in order to provide services when immediate family live in a long-term 

care facility on tribal lands; and,

· Ensure that, if a tribe owns or operates a long-term care facility, there are clear lines of 

business and distinctions between the facility operations and the services (paid or 

volunteer) of a person serving as a representative of the Office of the Ombudsman.

The requirement to address conflicts of interest is not new and may require additional steps to 

provide effective Ombudsman services to tribal elders. Developing relationships with tribes and 

understanding their organizational structure is critical to achieving conflict-free Ombudsman 

services.

 

12 Use of volunteers can provide an effective solution, yet may be particularly difficult to identify, train, and retain 

volunteers within tribal communities. ITCA noted that they do not use volunteers because of these difficulties.
Tribal Ombudsman Program Case Study

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Appendix A: List of Tribes and ITCA Involvement

The following table lists the 22 recognized tribes in Arizona. For each tribe, the table indicates 

which Title III, Title VI, and Title VII services under the Older Americans Act are provided by 

ITCA.

Tribe Title III Title VI Title VII

Ak-Chin Indian Community X X

Cocopah Indian Tribe X X

Colorado River Indian Tribes X X

Fort McDowell Yavapai Nation X X X

Fort Mojave Indian Tribe X X

Gila River Indian Community X X

Havasupai Tribe X X

Hopi Tribe X X

Hualapai Tribe X X

Kaibab Band of Paiute Indians X X X

Navajo Nation N/A N/A N/A

Pascua Yaqui Tribe X Subcontract

Pueblo of Zuni X X

Quechan Tribe X X

Salt River Pima-Maricopa Indian 

Community X X

San Carlos Apache Tribe X X

San Juan Southern Paiute X X X

Tohono O’odham Nation X Subcontract

Tonto Apache Tribe X X X

White Mountain Apache Tribe X Subcontract

Yavapai-Apache Nation X X

Yavapai-Prescott Indian Tribe X X
Tribal Ombudsman Program Case Study

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Appendix B: Methodology

The goal of this case study was to collect basic information about the structure, organization, 

operations, referral, and management procedures for the Tribal Ombudsman program in Arizona. 

Since the creation of the program, ACL had anecdotal evidence that the Tribal Ombudsman

program was unique and was accomplishing its goals of improving nursing facility quality of care 

and advocating for tribal members in an efficient and organized manner. As such, ACL was 

interested in understanding additional details about the Tribal Ombudsman program.

Lewin used a mixed-methods approach to this case study. First, Lewin conducted a brief and 

targeted literature and online review to gather basic information about the Ombudsman program 

generally and the Tribal Ombudsman program specifically. Second, Lewin conducted in-depth 

structured interviews to gather qualitative data about the Tribal Ombudsman program. Third, 

Lewin collected program-level quantitative data from ITCA to provide dimension about the Tribal 

Ombudsman program. All case study data collection activities were completed at the request of 

ACL by Lewin staff in consultation with Wendell Holt, a subject matter expert in tribal elder 

services.

Targeted Literature Review and Information Gathering

To begin information gathering, Lewin conducted several conference calls with leadership at ACL 

during July and August 2019. These conversations built the team’s knowledge about the broader 

national Ombudsman program and how the Tribal Ombudsman program may vary from the 

broader program. Additionally, Lewin reviewed publicly available information about the 

Ombudsman program as well as any previously completed evaluation reports and other 

information. Lewin conducted internet searches during July and August 2019 to gather basic 

information about the Ombudsman program.

A Lewin team member and Mr. Holt attended the 2019 National Title VI Training and Technical 

Assistance Conference in Minneapolis in August 2019. The Title VI conference is a gathering of 

Title VI (i.e., tribal elder services) programs, which has some overlap with the Tribal Ombudsman

program at ITCA because ITCA also receives Title VI funding. During the conference, Lewin

collected contextual information on the American Indian aging services structure and how it 

interfaces with the Ombudsman system (i.e., Title VI vis a vis Title III, Title VII, etc.). Lewin also 

conducted a preliminary meeting with ACL representatives and ITCA staff members. At this 

meeting, ITCA staff provided Lewin with a set of suggested interviewees to develop a functional 

understanding of the Tribal Ombudsman program. Lewin used the information gathered during this 

phase of the study to develop the in-depth interview guides, as described below.

Qualitative Interviews

Lewin conducted a series of in-depth semi-structured individual interviews to collect information 

about the Tribal Ombudsman program. Lewin guided the interviews using a standard interview 

guide that was developed following the targeted literature and information collection process 

described above (see Appendix C for the interview guide). The interview was organized into 

sections related to Tribal Ombudsman program characteristics; Tribal Ombudsman program 

origination and operations; trust and cultural competency; complaint processing; and, program 

outcomes, successes, and challenges.
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Interviewees were identified using a modified snowball method. First, Lewin consulted with ACL 

leadership to identify key informants at the ITCA and DES. Next, this initial slate of informants 

was contacted via email and telephone to ask for names of additional individuals who would have 

information about the Tribal Ombudsman program. The list of names was reviewed and vetted 

with ACL leadership prior to conducting interviews. This process resulted in a final list of 12 

individuals who were contacted to complete in-depth interviews.

Identified individuals were contacted via email and phone to make arrangements for interviews. 

Most interviews were completed in-person onsite in Arizona. Additional interviews were 

completed via phone. Interviews were completed between August 15, 2019 and October 31, 2019. 

For ease of scheduling, several interviews were completed as a group interview session during an 

on-site visit with ITCA during September 17-19, 2019. A list of final interviewees is provided in 

Appendix D.

All interviews were audio recorded using digital recorders after obtaining consent for recording. 

Lewin staff then transcribed the interviews and loaded transcriptions into ATLAS.ti (version 

7.5.18) for coding and analysis.

Lewin used a process based on grounded theory concepts for analyzing the qualitative interview 

data. First, Lewin developed a preliminary list of codes (i.e., labels and categories) in collaboration 

with ACL. Two Lewin analysts independently coded each interview using the preliminary list of 

codes as well as adding new codes throughout the coding process. The final code categories are 

referrals and triage, relationships, and trust and cultural competence. The case study results are 

presented using these categories.

Quantitative Data

Lewin collected quantitative data from ITCA regarding the volume of services provided by all 

Tribal Ombudsman programs (i.e., ITCA and its three subtracted entities) in Arizona for FY 2017-

FY 2019. Quantitative data included the number of clients and types of facilities served by each 

Tribal Ombudsman program per quarter. Quantitative information ultimately was of limited 

usefulness for the purposes of the study and therefore not reported in the final case study.
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Appendix C: Interview Protocol and Guide

Note regarding the structure of the interview protocol: This interview protocol includes guiding 

questions within each major domain, followed by specific prompts to ensure collection of more 

granular information. The interviewer will begin by asking each interviewee the guiding question. 

Depending on the answer provided by the interviewee, the prompts will be used to ensure that 

topics of interest are captured.

At the start of each interview, read the following introduction:

Thank you for taking the time to join us today. The Lewin Group, with its partner Wendell Holt, 

are under contract with the Administration for Community Living to perform a case study of the 

ITCA Tribal Ombudsman program.

The purpose of this interview is to better understand the founding and operations of the ITCA 

Ombudsman program, aspects that make the program unique, and aspects that are replicable.

Most interviews will take one hour. With your permission, we would like to record the interview. 

This will assist us with note-taking and analysis. Thank you in advance for taking the time to speak 

with us.

Introduction (For all interviewees)

Organizational Characteristics

Guiding question: Briefly describe your organization and how it interacts with the ITCA Tribal 

Ombudsman program.

Prompts (to be used as needed): 

· Please describe your role within the broader organization? 

· How does your organization work with the ITCA Ombudsman program?

· Please describe the reporting structure of your organization in relation to the Ombudsman 

program?

Program Origins

Guiding question: We are interested in understanding the founding and early development of the 

Tribal Ombudsman program. Please describe your organization’s role and your knowledge of the 

early years of the program?

Prompts (to be used as needed):

· Please describe your organization’s role in the founding of the ITCA Ombudsman 

program? 

· Why did your organization decide to participate in the Tribal Ombudsman program?

· What were key events that led to the founding of the program?

· Why was it created? What problem was the program seeking to fix?

· What environmental factors influenced the model of the Tribal Ombudsman program 

during its creation?
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· What made it difficult to establish? What were the catalysts for establishing the program?

§ Could you describe any major changes to the Ombudsman program since it was 

established?

Operational Questions (Interviewee specific)

Operations (For ITCA)

Guiding question: We are interested in understanding how the Tribal Ombudsman system 

operates. Please describe the overall operations of the program?

Prompts (to be used as needed):

· What organizations other than the ITCA are involved and what are their respective 

responsibilities?

· How many complaints/cases does the Tribal Ombudsman program handle annually? How 

has this number changed over time?

· Please describe your current relationship with Arizona DES and Adult Protective Services. 

How does that relationship support the Tribal Ombudsman system?

· Are there differences in the program for how they serve the urban populations (e.g.,

Phoenix, Flagstaff)? What do you know about how those tribal elders receive Ombudsman

services from ITCA?

Trust/Cultural Competency (For ITCA)

Guiding question: We are interested in the role trust plays in the effectiveness of the Tribal 

Ombudsman system. How would you describe the role that trust plays in this system and in this 

community?

Prompts (to be used as needed):

· What are the cultural nuances surrounding Native identity within Arizona? What is the 

framework around which the idea of an individual being Native is constructed and/or 

appraised by others who identify as Native?

· How would you describe cultural competence in terms of the Tribal Ombudsman 

system? What aspects of the program are different from other Ombudsman programs 

because of the cultural needs of the population?

· Are there specific policies in place to ensure client trust and comfort?

· How does the system identify someone as a tribal member? (note, this question is 

included in multiple domains but only needs to be answered once.)

Complaint Processing (ITCA) 

Guiding question: Describe how ITCA receives a complaint, how it is processed, investigated, 

and resolved.

Prompts (to be used as needed):

· How do you interact with other Ombudsman programs in Arizona? Do they transfer cases 

to you? How does the transfer process work? (i.e., do they call you? How do you gather 

information?) Do you receive cases that are outside your catchment area/from other tribes? 

How do you handle those cases?
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· You’ve mentioned before that there is sometimes a circular nature of referrals with Adult 

Protective Services. What strategies do you use to resolve these situations when they 

arise?

Operation (DES)

Guiding question: Describe how DES supports the Tribal Ombudsman program run by ITCA and 

what activities DES engages in to support the program.

Prompts (to be used as needed):

· Describe the current relationship between the DES and the ITCA Ombudsman program?

· Describe the process for referring clients to the tribal Ombudsman program?

· How does DES determine when to refer a complaint to the ITCA Tribal Ombudsman 

program?

· How does the system identify someone as a tribal member? (note, this question is 

included in multiple domains but only needs to be answered once.)

· Are there examples of cases that involve a client who is American Indian and an 

Ombudsman other than the ITCA processes and close the case?

· How would you say the ITCA Tribal Ombudsman differs from other Ombudsman 

programs?

· What do you know about how tribal elders are served outside the catchment area of the 

ITCA?

· Are there other Ombudsman programs within the state serving the Indian population?

Ombudsman Outcomes, Successes and Challenges (All interviewees)

Guiding question: How would you describe the tribal Ombudsman program’s results – in terms of 

outcomes, successes, and future challenges?

Prompts (to be used as needed):

· What have been the greatest challenges for the Tribal Ombudsman program? Of those you 

listed, which one was the greatest challenge.

· Are there particular stories that you’ve heard that would be helpful for us to hear to better 

understand the program?

· What have been the unintended consequences from the program?

· What aspects of the ITCA Tribal Ombudsman approach do you think could apply in other 

areas? Other populations?

· Any important lessons to share with other Ombudsman programs?
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Appendix D: List of Interviewees

Name Title/Role Organization

Cindy Saverino Community Action and Aging Programs 

Administrator Arizona Department of Economic Security

Michael Coen LTC Ombudsman Staff Arizona Department of Economic Security

Stacie Austin LTC State Ombudsman Arizona Department of Economic Security

Elizabeth Wood Human Services Worker II (former LTC 

State Ombudsman) Arizona Department of Economic Security

Travis Lane Assistant Director ITCA

Monique Sosei Program Analyst ITCA

Laurai Atcitty Area Agency on Aging Director ITCA

Flor Olivas Tribal Ombudsman Specialist ITCA

Stephanie Barehand Public Benefits/Independent Living 

Support Specialist ITCA

Remi Escamilla Tribal LTC Ombudsman Pascua Yaqui

Michelle Manuel Tribal LTC Ombudsman Pascua Yaqui

Ralph Gomez Adult Protective Services/Social Worker Pascua Yaqui