During a 1971 helicopter ride to a speech in Chicago, President Nixon and former Commissioner on Aging Arthur S. Flemming were discussing the President’s presentation of initiatives to improve nursing home care. By the time they arrived in Chicago, a new idea was added: the formation of a nursing home ombudsman program.
The idea behind the creation of the Long-Term Care Ombudsman Program (LTCOP) came from involving the community to ensure nursing homes were providing appropriate care for their residents. Engaging trained volunteers who could visit and establish relationships with the residents was the basis for the program.
The next year, demonstrations were undertaken in five states. Due to the success of those efforts, in 1975, the Older Americans Act (OAA) was amended to include funding for Ombudsman programs in every state. Throughout the next 49 years, the LTCOP has proven to be a strong and vital program assisting residents of both nursing homes and residential care facilities in ensuring their rights are protected.
I joined the LTCOP in 1989 as the Missouri State Ombudsman. When asked by Edwin Walker (former Missouri Division of Aging Director and former Deputy Assistant Secretary for Aging at the Administration for Community Living) to take on this role, I was a bit hesitant. What did I know about nursing homes and advocating for the people who lived in them? Nothing!
Over the next 23 years, I learned a lot. I had joined a nationwide group of people who worked hard to ensure the voices of residents were heard and listened to.
The word “Ombudsman” means to speak on behalf of another person. Unlike the traditional Ombudsman who are neutral when receiving complaints, the Long-Term Care Ombudsman is an advocate. The resident is our client, no matter who brings a complaint or concern to the program. This requires the Ombudsman to visit with the resident to determine if the complaint is something the resident wants the Ombudsman to work on. This might involve educating the resident about their rights (empowering them to handle the complaint on their own) or discussing options on how the complaint might be resolved and then determining whether the resident wants the Ombudsman to assist them or handle the issue on their behalf.
‘One common complaint is when a resident receives a notice of involuntary discharge from a facility.'
One common complaint is when a resident receives a notice of involuntary discharge from a facility. The Ombudsman is often instrumental in determining whether the reason for discharge is appropriate, helping the resident file an appeal, ensuring discharge is to a safe location, and that the residents’ rights are being respected.
Responding to complaints and working toward a resolution that satisfies the resident is the biggest part of an Ombudsman’s job. In 2023, the LTCOP managed 202,894 complaints. Ombudsmen visited 91% of the 15,593 nursing homes and 54% of the 62,244 residential care communities. The program also provided more than 500,00 instances of information and assistance and 7,800 community education opportunities.
Most of these interactions involve informing people of the rights of residents (to be treated with dignity and respect, the right to make choices such as when to get up and what to eat, being able to choose their own physician, etc.). Many Ombudsmen work with residents and families to establish or enhance resident or family councils. These councils can be a “safe” place for people to bring up issues.
It may seem trivial, but one resident council, with the assistance of an ombudsman, was able to convince the city to exchange the “dead end” sign at the top of their street to “no exit.” Living in a long-term care facility doesn’t mean the end of being a member of the community and expressing one’s desires and opinions.
Unlike Adult Protective Services, the state survey agency, or law enforcement, the Ombudsman program cannot impose a penalty or fine or force the facility to take action. The strength of the program, however, is in being armed with information, such as regulatory requirements or best practices, being tenacious, and creatively working toward solutions to the problem at hand.
In addition to individual complaints, the Ombudsman program also works on systemic issues. These are issues which affect many or all of the residents in a facility or multiple facilities. There are times when this involves working with corporations, legislators, city councils, and/or state or federal agencies.
One example of this is working to increase the personal needs allowance (PNA) for residents utilizing Medicaid. The PNA is the amount of money a resident may keep for personal expenditures like buying new clothes, small gifts for grandchildren, hair care beyond just a simple cut, paying the cell phone bill, etc. The current federal minimum is $30/month. Over the years, many Ombudsman programs have successfully worked to get their state to increase that amount, giving residents more dignity and control over their lives.
Other activities Ombudsmen do include supporting resident and family councils; holding in-services (trainings) for staff; educating the community about long-term care issues, resident rights, and quality care; helping people who are looking for long-term care find the best placement; and helping people transition out of nursing homes and back into the community.
Ombudsmen help people looking for long-term care find the best placement, and transition back to the community.
And, for more than 30 years, the OAA has required that ACL fund a national resource center. The National Ombudsman Resource Center (NORC) is located at The National Consumer Voice for Quality Long-Term Care (Consumer Voice).
I have worked at NORC since 2016, answering questions and providing technical assistance and training to state and local Ombudsmen. During that time, I have seen significant changes in the issues Ombudsmen deal with, as well as in the long-term-care system. Complaints now are more complex, residents living in facilities have greater care needs, and there has been a tremendous increase in assisted living and board and care residences, putting greater stress on the Ombudsman program.
Most complaints (missing clothes, laundry staff, being offered a second choice for a meal, dietary staff, etc.) can be resolved by talking to the correct staff person. But complaints requiring more work and involving multiple people are becoming more common. For instance, there might be several family members speaking on behalf of a resident who can't speak for themselves. This can lead to facilities being given varied instructions, causing staff confusion over who to listen to. Absent written instructions regarding who is in charge (such as a Durable Power of Attorney) leaves facility staff unsure and frustrated.
The LTCOP may need to hold a family meeting to try to get them to work together in the best interest of the resident. Cases where a guardian, who is either not communicating with the facility or not acting in the best interest of the resident, might involve working with the legal system to change or remove a guardianship.
The number of residential care facilities which LTCOPs may visit has reached a staggering 62,244, which means the number of residents (and those with greater care needs) has also grown. When these facilities were first conceived, there were very few people with dementia living in them. Now it is estimated that 40% of residents have some form of dementia.
As for the future? There are some interesting challenges on the horizon. First, the number of people signing up to volunteer has been decreasing for the past 10 years. COVID-19 hit the program especially hard and local programs are working diligently to build back their volunteer base. Also, keeping up with higher acuity levels, the changing nature of those living in long-term care facilities (residents tend to have more severe conditions), and changes in the long-term care system—where and how people receive long-term care services, etc.—are all further challenged due to the explosion in numbers of assisted living facilities, which has significantly increased demands on the program. Yet funding and resources for the program have not kept pace.
As many states approach the 50th anniversary of their Ombudsman program, I’m still proud to say that the LTCOP is a shining example of the many wonderful programs contained in the Older Americans Act.
For more information about the Long-Term Care Ombudsman program, visit the NORC website: https://ltcombudsman.org/about/about-ombudsman
Carol Scott is manager of the LTC Ombudsman Program & Policy at The National Consumer Voice for Quality Long-Term Care.
Photo credit: Shutterstock/pikselstock
