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Older Americans Act: Long-Term Care
Ombudsman Program
Kirsten J. Colello
Specialist in Health and Aging Policy
May 31, 2011
Congressional Research Service
7-5700
www.crs.gov
RS21297
CRS Report for Congress
P
repared for Members and Committees of Congress
c11173008
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Older Americans Act: Long-Term Care Ombudsman Program
Summary
Quality of care in long-term care settings has been, and continues to be, a concern for federal
policymakers. The Long-Term Care (LTC) Ombudsman Program is a consumer advocacy
program that aims to improve the quality of care, as well as the quality of life, for residents in
long-term care settings by investigating and resolving complaints made by, or on behalf of, such
residents. Established under Title VII of the Older Americans Act (OAA), the Administration on
Aging (AoA) within the Department of Health and Human Services (HHS) administers the
nationwide program. As of 2009, there were 53 state LTC Ombudsman Programs operating in all
50 states, the District of Columbia, Guam, and Puerto Rico, and 573 local programs. Title VII
programs received $21.9 million in FY2010 and $21.8 million in FY2011, reflecting the across-
the-board 0.2% rescission required by P.L. 112-10, the Department of Defense and Full-Year
Continuing Appropriations Act, 2011. Total FY2009 funding for ombudsman activities from all
sources combined (federal and non-federal) was $84.9 million, the most recent year for which
data on funding from all sources are available. Of that total, 60% ($51.2 million) represented
funding from federal sources. The OAA Amendments of 2006 (P.L. 109-365) authorized
appropriations for the LTC Ombudsman Program through FY2011.
Due to the requirement that ombudsmen investigate and resolve complaints of all residents in
residential long-term care facilities, the workload of staff and volunteers is substantial. In
FY2009, ombudsmen reported just over 16,600 nursing facilities and about 52,400 other
residential long-term care facilities operating nationwide. This translated to a nationwide ratio of
one paid ombudsman for every 57 facilities and one paid ombudsman for every 2,411 resident
beds. With respect to staffing, the program receives significant support from volunteers. In
FY2009, over 1,200 paid staff and about 8,700 certified volunteers investigated just over 233,000
resident complaints. Issues regarding residents’ care were the chief complaint in nursing homes,
followed by residents’ rights issues in FY2009. Among residents in other long-term care facilities,
the top complaint categories in FY2009 were quality of life and residents’ rights.
Legislation enacted in the 111th Congress provides some additional support to state LTC
Ombudsman Programs. The Patient Protection and Affordable Care Act (PPACA; P.L. 111-148,
as amended) includes, among its many provisions, programs to prevent elder abuse, neglect, and
exploitation. Included in these “elder justice” activities are two types of grant programs that
directly assist state LTC Ombudsman Programs. The first aims to improve the capacity of
ombudsman programs while the second addresses ombudsman training with respect to elder
abuse. Both authorize appropriations to fund these initiatives.
This report describes the LTC Ombudsman Program, including the program’s legislative history,
administrative function, and FY2009 funding amounts by source. It also identifies selected issues
for federal policymakers, including staffing and resources; in-home care ombudsman; and
specialized ombudsman training.
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Older Americans Act: Long-Term Care Ombudsman Program
Contents
Background ................................................................................................................................ 1
Legislative History...................................................................................................................... 1
Administrative Function.............................................................................................................. 2
Other Resident Advocacy Activities ............................................................................................ 3
Authorization and Funding.......................................................................................................... 4
Staffing ....................................................................................................................................... 5
Workload .............................................................................................................................. 7
Training ................................................................................................................................ 7
Program Data and Resident Complaints ...................................................................................... 8
Program Evaluation .................................................................................................................... 9
Related Legislation ..................................................................................................................... 9
Issues for Congress ................................................................................................................... 10
Figures
Figure 1. Number of Long-Term Care Facilities, by Facility Type................................................ 6
Tables
Table 1. Long-Term Care Ombudsman Program Funding, by Source........................................... 5
Contacts
Author Contact Information ...................................................................................................... 11
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Older Americans Act: Long-Term Care Ombudsman Program
Background
Quality of care in long-term care settings has been, and continues to be, a concern for federal
policymakers. The Long-Term Care (LTC) Ombudsman Program is a consumer advocacy
program that aims to improve the quality of care and quality of life for residents in nursing
facilities and other residential care settings by responding to the needs of those facing problems in
such facilities. Ombudsmen help to resolve resident’s complaints about the quality of their care
and protect resident rights. Resident-focused ombudsmen services complement those of federal
and state staff who enforce facility-focused quality standards that are required under statute or
regulation. Among their many functions, ombudsmen provide services to assist residents in
protecting their health, safety, welfare, and rights such as representing residents before
governmental agencies or recommending changes to current law or regulation. Ombudsmen are
available to help all long-term care facility residents, not just those residents in nursing facilities
certified by Medicare and Medicaid, including those residing in assisted living facilities, board
and care homes, and other similar adult residential care settings.
This report describes the LTC Ombudsman
What Is an Ombudsman?
Program authorized under the Older
The Old Norse term ombudsman essentially means
Americans Act (OAA). The OAA
“representative.” An ombudsman is an individual who
Amendments of 2006 (P.L. 109-365)
investigates and attempts to resolve complaints and
problems on behalf of citizens against businesses,
authorized appropriations for OAA-funded
institutions, and officials. The modern day use of the
activities, including the LTC Ombudsman
term ombudsman began in 19th-century Sweden with the
Program, through FY2011. The 112th Congress
establishment of the Swedish Parliamentary Ombudsman
may choose to reauthorize the Act. In doing
to safeguard citizens’ rights by establishing an agency
so, federal policymakers may consider
independent of the executive branch.
amending or deleting existing authorities
under the Act or establishing new authorities, including those under the LTC Ombudsman
Program. In addition, Congress will likely consider annual appropriations for LTC Ombudsman
Program activities as well as appropriations for newly established authorities enacted under the
Patient Protection and Affordable Care Act (PPACA, P.L. 111-148, as amended) that support the
program. This report briefly describes the program’s legislative history, administrative function,
and funding. Next, it presents program data for FY2008, the most recent year for which data are
available. The report then provides findings from an Institute of Medicine (IOM) evaluation and
other studies. Finally, it summarizes legislation enacted in the 111th Congress that authorizes
grants to improve program capacity and provide training on elder abuse and identifies further
issues for Congress.
Legislative History
Created in 1972 as a Public Health Service (PHS) demonstration project in five states, authority
for administering the ombudsman demonstration program was transferred to the Administration
on Aging (AoA) within the Department of Health and Human Services (HHS) in 1973. The
results of the demonstration effort led to statutory authority under the Older Americans Act
(OAA)1 in 1978 (P.L. 95-478). In 1987, the program was given a separate authorization of
1 In 1978 Congress amended the OAA (P.L. 95-478) to include a requirement that each state develop a LTC
Ombudsman Program in order to protect the health, safety, welfare, quality of care, and rights of institutionalized
(continued...)
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Older Americans Act: Long-Term Care Ombudsman Program
appropriations (P.L. 100-175) and, in 1992, the program was incorporated into a new Title VII of
the Act authorizing vulnerable elder rights protection activities (P.L. 102-375). Also in 1992, a
provision was added to the OAA requiring AoA to establish a permanent National Ombudsman
Resource Center. The most recent amendments to the OAA in 2006 (P.L. 109-365) made no major
changes to the program.
Administrative Function
There are 53 state LTC Ombudsman Programs operating in all 50 states, the District of Columbia,
Guam, and Puerto Rico, and 573 local programs as of 2009. The AoA’s National Ombudsman
Reporting System (NORS) compiles national statistics relating to ombudsman activities. This
information includes number, status, and type of cases reported to state and local ombudsman
programs; data on staff, volunteers, and funding; and, other ombudsman activities.
The OAA requires State Units on Aging to establish an Office of the State Long-Term Care
Ombudsman. The functions of the state ombudsman programs are mandated by law and include
• identifying, investigating, and resolving resident complaints;
• protecting the legal rights of residents, advocating for systemic change, and
providing information and consultation to residents and their families; and
• publicizing issues of importance to residents.
Complaints investigated by ombudsmen relate to actions, inactions, or decisions of long-term care
providers or other agencies that adversely affect the health, safety, welfare, or rights of residents.
Among its other responsibilities, the Office is to analyze and monitor federal, state, and local
policies that affect residential long-term care facilities.
The federal law requires that a full-time ombudsman administer the program at the state level;
local ombudsmen may be designated by the state and are considered to be representatives of the
Office. According to AoA, most state ombudsman programs (36 states and Puerto Rico) are
located within State Units on Aging. Another five ombudsman programs are located in another
government agency, outside the State Unit on Aging. Nine states, the District of Columbia, and
Guam have ombudsman programs that are located outside of state government in other
organizations, such as a legal services agency or protection and advocacy agency.2 Variation
exists partly because the OAA gives each state discretion in determining many aspects of the
ombudsman program. For example, states can decide
• where ombudsman programs may be located organizationally within the state,
• whether enabling legislation should be passed at the state level, and
(...continued)
residents in nursing facilities, board and care homes, assisted living facilities, and other similar facilities. For further
information, see CRS Report RL33880, Funding for the Older Americans Act and Other Administration on Aging
Programs, by Angela Napili and Kirsten J. Colello.
2 National Association of State Units on Aging, Long-Term Care Ombudsman Program: Structure, Responsibilities,
Quality and Funding, September 2003.
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• whether additional funding will be made available through state and local
sources.3
These differences mean that the structure, operation, and effectiveness of the ombudsman
programs can vary from state to state.
Other Resident Advocacy Activities
In addition to resolving resident complaints in long-term care facilities, ombudsmen provide a
variety of other educational and advocacy activities to benefit long-term care residents, including
participation in a number of federal initiatives. These activities range from involvement with
quality improvement initiatives to informing nursing home residents and family members about
various long-term care options, including home and community-based care. For example, the
Centers for Medicare and Medicaid Services (CMS) encourages ombudsmen to communicate and
work collaboratively with Quality Improvement Organizations (QIOs).4 Ombudsmen may assist
QIOs in identifying and working with facilities on quality assessment and improvement efforts or
assist residents and family members with the use of quality measures in nursing home selection.5
Ombudsmen may also assist residents transitioning from nursing homes to private homes or other
residential care facilities. In doing so, ombudsmen may refer residents and family members to
community resources or monitor the discharge planning process. Some ombudsman programs are
actively involved in federal nursing home transition initiatives such as the CMS Money Follows
the Person Rebalancing Demonstration program. Ombudsman programs may participate in state
level coalitions and advisory committees that oversee these initiatives.6 According to information
solicited from state ombudsmen by the National Association of State Units on Aging and
Disabilities (NASUAD), the ombudsman’s knowledge of community resources is important in
assuring that referrals to the appropriate services are made. 7 In some states, ombudsmen have
received training about such initiatives in order to better assist residents with transitions.
In addition, ombudsman programs in 12 states are authorized or mandated under state law to
advocate on behalf of consumers who receive in-home long-term care. According to a 2007 report
of state Home Care Ombudsman programs, the majority of these states have responsibility for
complaints regarding services provided under the state’s Medicaid home and community-based
3 For further information, see J. Harris-Wehling, J. Feasley, and C. Estes, eds., Real People Real Problems: An
Evaluation of the Long-Term Care Ombudsman Programs of the Older American Act, Washington, DC: Institute of
Medicine (IOM), 1995.
4 Sections 1152-1154 of the Social Security Act require the Secretary of HHS to establish Quality Improvement
Organizations (QIOs). According to CMS, QIOs are private, mostly not-for-profit organizations staffed by doctors and
other health care professionals who are trained to review medical care, help beneficiaries with complaints about the
quality of care, and implement quality improvements. CMS contracts with one organization in each state, the District of
Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as the QIO contractor. For more information on QIOs see
http://www.cms.gov/qualityimprovementorgs/.
5 Centers for Medicare and Medicaid Services, Nursing Home Quality Initiative: Relationship of Quality Improvement
Organizations and State Offices of the Long-Term Care Ombudsman, https://www.cms.gov/NursingHomeQualityInits/
downloads/NHQIombudqio472a200512.pdf.
6 For more information on CMS’ Money Follows the Person Rebalancing Demonstration see https://www.cms.gov/
DeficitReductionAct/20_MFP.asp.
7 National Association of State Units on Aging, Strategy Brief: Ombudsman Program Involvement in Nursing Home
Transition Activities, December 2004.
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Older Americans Act: Long-Term Care Ombudsman Program
waivers.8 States also reported that in-home care ombudsmen cover complaints regarding home
health agency services and home care services that may be privately funded, state funded, or
funded through the OAA. In general, state Home Care Ombudsman programs are supported by
state funds.
Authorization and Funding
The OAA Amendments of 2006 (P.L. 109-365) authorized appropriations for the LTC
ombudsman program through FY2011. Ombudsman services are authorized under two separate
titles of the OAA:
• Title III – Grants for States and Community Programs on Aging, and
• Title VII – Vulnerable Elder Rights Protection Activities.
Title III authorizes grants to states for supportive services and senior centers that provide for a
wide range of social services, including ombudsman services.9 Title VII authorizes grants to states
for Chapter 2 (the LTC Ombudsman Program) and Chapter 3 (the Elder Abuse Prevention
Program). Under Chapter 3, some states choose to perform elder abuse prevention activities
through the LTC Ombudsman Program.
Title VII programs received $21.9 million in FY2010 and $21.8 million in FY2011, reflecting the
across-the-board 0.2% rescission required by P.L. 112-10, the Department of Defense and Full-
Year Continuing Appropriations Act, 2011.10 While the majority of federal funding for
ombudsman activities comes from appropriations for Titles III and VII of the OAA, the program
also receives substantial non-federal support. Table 1 shows total support for ombudsman
activities in FY2009, the most recent year for which data on funding from all sources are
available. Total FY2009 funding for ombudsman activities from all sources combined (federal
and non-federal) was $84.9 million. Of that total, 60.3% represented funding from federal
sources, with 32.3% from Title III funds, 22.5% from Title VII funds, and 5.5% from other
federal funds. In FY2009, nonfederal funding represented 39.7% of total support (32.0% state
funding and 7.7% local funding).
8 M. Miller, Home Care Ombudsman Programs Status Report: 2007, National Association of State Units on Aging,
November 2007. According to the AoA, in FY2010, Delaware initiated development of an in-home care ombudsman
program. Georgia also initiated a pilot program for in-home care in 3 of its 12 areas limited to the Money Follows the
Person Demonstration program.
9 For more information on how funding under Title VII is allocated to states, see CRS Report RS22549, Older
Americans Act: Funding Formulas, by Kirsten J. Colello.
10 HHS, The Department of Health and Human Services: FY 2011 Operating Plans, http://www.hhs.gov/asfr/ob/
docbudget/2011operatingplan.html.
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Table 1. Long-Term Care Ombudsman Program Funding, by Source
FY2009
Total FY2009 funds (in millions)
$84.9 100%
Total $51.2
60.3%
Title III, OAA
$27.5
32.3%
Federal funds
Chapter 2: ombudsman program
$16.7
19.6%
Title VII, OAA Chapter 3: elder abuse prevention
$2.4
2.9%
Other $4.7
5.5%
State funds
$27.2 32.0%
Local funds
$6.6
7.7%
Source: CRS analysis based on AoA, 2009 National Ombudsman Reporting System Data Tables: Table A-9 Long-
Term Care Ombudsman Program Funding.
Note: Data may not sum to totals due to rounding.
From FY2000 through FY2009, the share of federal funding for LTC Ombudsman Program
activities overall has remained relatively constant (59.1% vs. 60.3%, respectively), while the
proportion of state funding increased from 27.6% to 32.0% and spending at the local level
declined from 13.4% to 7.7%. Compared to the previous fiscal year, the share of federal funding
increased from 56.7% to 60.3% from FY2008 to FY2009, with a decrease in the proportion of
program funding from state governments (35.5% vs. 32.0%, respectively) and relatively similar
funding amounts from local governments (7.8% vs. 7.7%, respectively).
Staffing
In FY2009, there were 1,203 paid staff (full-time equivalents) in state LTC Ombudsman
Programs, an increase of 24% since FY2000.11 Despite this increase, the program still relies
heavily on volunteers to carry out program responsibilities. Nine out of every ten ombudsman
staff serve as volunteers. In FY2009, there were just under 11,000 total volunteers, about 8,700 of
which were certified to investigate complaints. While the number of paid ombudsman staff has
increased from FY2000, the total number of volunteers decreased 19% during this same time
period (from just over 13,600 in FY2000). In FY2009, 48 state ombudsman programs reported at
least one certified volunteer and one state (MD) reported volunteers, none of which were
certified. Four states (IA, NV, SD, WY ) reported no volunteer activity during this period.
The 1995 IOM evaluation along with a study done by the Office of Inspector General (OIG) in
HHS (1991) acknowledged the importance of volunteers as a contributing factor to high
complaint resolution rates in this program.12 However, the IOM evaluation advised that adequate
11 For further information, see the AoA’s AGing Integrated Database (AGID) which includes data for the National
Ombudsman Reporting System (NORS), at http://www.agidnet.org/.
12 For further information, see Office of Inspector General (OIG) Report OEI-02-90-02120, Successful Ombudsman
Programs; OEI-02-90-02121, Ombudsman Output Measures; and, OEI-02-90-02122, Effective Ombudsman Programs:
Six Case Studies; J. Harris-Wehling, J. Feasley, and C. Estes, eds., Real People Real Problems: An Evaluation of the
Long-Term Care Ombudsman Programs of the Older American Act, Washington, DC: Institute of Medicine (IOM),
1995.
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methods for recruiting, training, and supervising volunteers are essential to maximum utilization
of ombudsman program volunteers. State programs have different procedures for certification of
volunteers, varying from required classroom training to tests for certification. Data from AoA’s
NORS report that about 8 out of 10 volunteers (79%) were trained and certified to investigate
complaints in FY2009, a 3% increase since FY2000.
In FY2009, ombudsmen reported just over 16,600 nursing facilities and almost 52,400 other
residential long-term care facilities operating nationwide.13 Since FY2000 the total number of
regulated facilities has increased 13% from almost 61,000 to more than 69,000 in FY2009 (see
Figure 1). This increase is due to an increase in assisted living facilities, board and care homes,
and other similar facilities, which more than offset the decrease in nursing homes over the past
eight years.
Figure 1. Number of Long-Term Care Facilities, by Facility Type
FY2000 to FY2009
60,000
Board & Care
52,371
49,171 50,116
50,000
46,042
46,103
47,084
45,830
44,669
44,718
43,102
40,000
lities
ci
30,000
Fa
of
ber
Nursing Facility
17,799 17,710
20,000
17,165 17,002 16,902 16,862
um
16,750 16,746 16,749 16,653
N
10,000
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year
Source: CRS analysis based on AoA, 2009 National Ombudsman Reporting System Data Tables: Table A-6-A Long-
Term Care Ombudsman Program Funding.
Note: The number of nursing facilities and board and care homes and similar facilities includes those regulated
(licensed or registered) in the state. Under the OAA, the ombudsman program covers all such facilities, whether
regulated or unregulated by the state; however, according to the OMB instructions for completing the Long
13 Other residential long-term care facilities include board and care homes and similar facilities, such as residential care
facilities, adult congregate living facilities, assisted living facilities, foster care homes, and other adult care homes
similar to a nursing facility or board and care home that provides room, board, and personal care services to a primarily
older residential population.
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Term Care Ombudsman Program Reporting Form for NORS, it would not be possible for the program to
provide the total number of unregulated facilities and beds. Therefore, the actual number of these facilities may
be higher. The number of nursing homes may be slightly higher than estimates by the Centers for Medicare and
Medicaid Services (CMS), which include only nursing homes certified to participate in Medicare and/or Medicaid.
Workload
Due to the requirement that ombudsmen investigate and resolve complaints of all residents in
residential long-term care facilities, the workload of staff and volunteers is substantial, as shown
by the reported ratio of staff to facilities and beds. The nationwide ratio of paid ombudsman to
facilities was one ombudsman to every 57 facilities in FY2009, a somewhat smaller ratio than
reported in FY2000 (one ombudsman to every 62 facilities). Nationwide, there were a reported
2.90 million facility beds under the program’s jurisdiction (almost 1.74 million nursing home
beds and just over 1.16 million beds in other long-term care facilities) in FY2009. The nationwide
ratio of full-time paid ombudsman to facility beds was about one ombudsman per 2,411 beds, a
smaller ratio than reported in FY2000 (one ombudsman per 2,800 beds). However, it is important
to note that these ratios are nationwide, and each state has a unique ratio of paid ombudsman staff
per facility bed.14 The 1995 IOM study recommended a standard staffing ratio of one paid full-
time equivalent staff per 2,000 long-term care facility beds.
Despite the high number of facilities to be covered by each ombudsman, ombudsman staff and
volunteers visited 80% of nursing homes on a regular basis (defined as at least quarterly) in
FY2009. These visits were not in response to a complaint. The percentage of nursing homes
visited regularly by ombudsman staff was greater than visits by staff to other residential long-
term care facilities. The proportion of regular visits to assisted living and other long-term care
facilities was 45% in FY2009.
Training
State ombudsman programs are responsible for training new and existing staff. The OAA contains
only basic requirements for training and stipulates that the AoA is to develop model standards for
training long-term care ombudsman, both paid and unpaid volunteers. Furthermore, the law
stipulates that the state LTC Ombudsman is responsible for establishing procedures for training
representatives of the local ombudsman program based on the AoA standards and that training is
to be developed in consultation with representatives of citizen groups, long-term care providers,
and ombudsmen. In the absence of specific federal training requirements and/or required training
materials, many states have developed their own standards. Several states provide the training
directly through an individual who is responsible for conducting all of the training while some
states require local ombudsman programs to conduct training. State Long-Term Care Ombudsman
Programs have received assistance in developing training programs from the National Long-Term
Care Ombudsman Resource Center, operated by the National Consumer Voice for Quality Long-
Term Care.15
14 For further information, see 2009 National Ombudsman Reporting System Data Tables, at http://www.aoa.gov/
AoARoot/AoA_Programs/Elder_Rights/Ombudsman/National_State_Data/2008/Index.aspx.
15 The National Consumer Voice for Quality Long-Term Care is formerly known as the National Citizen’s Coalition for
Nursing Home Reform. For further information on training materials to assist states, see the National Ombudsman
Resource Center website at http://www.ltcombudsman.org/.
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Program Data and Resident Complaints
As advocates for residents’ rights in long-term care facilities, ombudsmen work to resolve
resident complaints. In FY2009, AoA data show that ombudsmen opened just over 161,000 new
cases of resident complaints and closed almost 158,000 cases in all types of facilities.16 Between
FY2000 and FY2009, the total number of cases closed increased by 15%.
Since 2000, resident care issues have been the primary complaint category in nursing homes.
Poor quality of care in nursing homes has been attributed to insufficient numbers of staff to care
for residents. However, the relationship between staffing and quality of care is complex and
includes a range of staffing-related issues such as wages and benefits, education, training,
experience, and staff turnover.17
The top five resident complaint categories in nursing homes for FY2009 were
(1) unheeded requests for assistance;
(2) problems with discharge planning or eviction notification and procedures;
(3) lack of dignity or respect for residents by staff;
(4) lack of quantity, quality, variety, and choice in food; and
(5) problems with organization or administration of medications.
These top five complaints have remained among the top 10 resident complaints in nursing homes
since FY2000.
Similarly, the top five resident complaint categories in other long-term care facilities for FY2009
have remained the same since FY2000 and were
(1) lack of quantity, quality, variety, and choice in food,
(2) problems with medication administration or organization,
(3) inadequate discharge or eviction notice or procedure,
(4) poor equipment or building conditions, and
(5) lack of dignity or respect for residents by staff.
In FY2009, the top five resident complaints in nursing homes and other long-term care facilities
accounted for over one-fifth of all complaints for each facility type.
16 According to the National Ombudsman Reporting System (NORS) Reporting Requirements Form (OMB No. 0985-
0005), a complaint is a concern brought to, or initiated by, the ombudsman for investigation and action by or on behalf
of one or more residents of a long-term care facility relating to health, safety, welfare, or rights of a resident. Each
inquiry involving one or more complaints constitutes an “opened” case, which then requires ombudsman investigation,
a strategy for resolution, and follow-up. A case is reported “closed” when none of the complaints within the case
require any further action on the part of the ombudsman and every complaint has been assigned the appropriate
disposition code.
17 J. Schnelle et al., Relationship of Nursing Home Staffing to Quality of Care. Health Services Research, 39(2): 225-
250, April 2004; R. Kane. Commentary: Nursing Home Staffing—More Is Necessary but Not Necessarily Sufficient,
39(2): 251-256, April 2004.
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Program Evaluation
The most recent national evaluation of the ombudsman program, conducted in 1995 by the IOM,
concluded that the program plays an important role in improving long-term care services, but is
understaffed and underfunded to carry out its broad and complex responsibilities.18 In March
1999, HHS’s OIG recommended that AoA work with states to strengthen the program by:
developing guidelines for a minimum level of program visibility that include criteria for the
frequency and length of regular visits, as well as the ratio of ombudsman program staff to long-
term care beds; further developing strategies for recruiting, training, and supervising more
volunteers; and establishing ways in which ombudsman programs can enhance collaboration with
the state nursing home survey and certification agencies, which are responsible for oversight of
nursing home care quality.19
A 2000 study of state ombudsman programs reaffirmed the importance of several factors
identified in the IOM evaluation as key to program effectiveness including sufficient funding,
staff, and volunteers; autonomy of ombudsman program in organizational placement within the
state; a supportive political or social environment; and strong interorganizational relationships.20
A study of local ombudsman programs conducted in two states, California and New York, in
2004, found wide variation both across and within each state’s program in terms of program
location (area agency on aging versus nonprofit organization) and the number of paid staff versus
volunteers. Despite reporting that their program budgets were inadequate to support their
mandated requirements, program coordinators in both states perceived their programs as
effective, more so in the nursing home setting than in board and care facilities. Program
coordinators in both states similarly identified staffing, resident care, and residents’ rights as the
most pressing issues.21
Related Legislation
In March 2010, President Obama signed into law a comprehensive health reform bill, the Patient
Protection and Affordable Care Act (PPACA; P.L. 111-148, as amended), and a package of
amendments to PPACA, the Health Care and Education Reconciliation Act of 2010 (HCERA;
P.L. 111-152). The Act is broad in its scope, making modifications to all major components of the
health care system, including financing and delivery of care as well as numerous provisions
intended to increase the health workforce, promote preventive services, and improve the quality
of care. Among its many provisions, PPACA also includes programs to prevent elder abuse,
neglect, and exploitation. These provisions were first introduced as the Elder Justice Act in 2002
and have been periodically reintroduced since that time. Included among these elder justice
activities enacted in PPACA are two types of grant programs that would directly assist state LTC
Ombudsman Programs. The first aims to improve the capacity of ombudsman programs while the
18 J. Harris-Wehling, J. Feasley, and C. Estes, eds., Real People Real Problems: An Evaluation of the Long-Term Care
Ombudsman Programs of the Older American Act, Washington, DC: Institute of Medicine (IOM), 1995.
19 OIG Report OEI-02-98-00351, Long-Term Care Ombudsman Program: Overall Capacity.
20 C. Estes, et al. State Long Term Care Ombudsman Programs: Factors Associated with Perceived Effectiveness, The
Gerontologist, vol. 44(1), pp.104-115, 2004.
21 C. Estes, Enhancing the Performance of Local Long Term Care Ombudsman in New York Sate and California:
Chartbook, University of California, San Francisco, 2006.
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Older Americans Act: Long-Term Care Ombudsman Program
second addresses ombudsman training with respect to elder abuse. Both authorize appropriations
to fund these initiatives.
Specifically, PPACA adds a new Section 2043 of the Social Security Act requiring the Secretary
to award grants to eligible entities with relevant expertise and experience in abuse and neglect in
LTC facilities or state LTC Ombudsman Programs to (1) improve the capacity of ombudsman
programs to respond to and resolve abuse and neglect complaints; (2) conduct pilot programs
with state or local ombudsman offices; and (3) provide support for such ombudsman programs
and pilot programs. It authorizes to be appropriated $5 million for FY2011, $7.5 million for
FY2012, and $10 million for each of FY2013 and FY2014. The section also requires the
Secretary to establish programs to provide and improve ombudsman training with respect to elder
abuse, neglect, and exploitation for national organizations and state LTC Ombudsman Programs.
It authorizes to be appropriated $10 million for each of FY2011 through FY2014.22 For FY2011,
no funding was provided for these newly authorized programs.
Issues for Congress
As the nation prepares for the growing older population and potential increase in demand for
long-term care services among the frail elderly, assuring quality of care in long-term care
facilities will likely remain a key issue for federal policymakers. In particular, the increasing
number of residential care facilities has placed pressure on state LTC Ombudsman Programs to
monitor quality of care in these settings. Ombudsmen indicated that regular visitation to these
facilities was often limited and in some cases nonexistent.23 Residents in assisted living facilities
are often less frail than nursing home residents; however, some receive services paid for by
Medicaid home and community-based waivers and must meet the state’s definition for nursing
home eligibility. Policymakers may choose to address greater ombudsman program oversight of
residential care facilities through additional staffing and resources for ombudsman programs and
specialized training regarding the needs of these residents.
The growth in home and community-based services and increase in demand for such services has
also drawn attention to potential problems with quality of care in home-based settings.
Stakeholders have identified a perceived need for an in-home care ombudsman program to
address quality of care issues among these long-term care recipients.24 Policymakers may choose
to consider extending ombudsman activities to older persons receiving long-term care in their
own home. These activities are not among those financed by the Older Americans Act. However,
without additional staff or resources to expand ombudsman activities to home settings, federal
expansion of the program may overwhelm an already strained system. Moreover, the number of
additional staff and amount of resources needed to provide adequate ombudsman services to
home care recipients is not known.
22 Section 6703 of PPACA adds a new subtitle B, Elder Justice, under Title XX of the Social Security Act. For further
information on these elder justice provisions, see CRS Report R41278, Public Health, Workforce, Quality, and Related
Provisions in PPACA: Summary and Timeline, coordinated by C. Stephen Redhead and Erin D. Williams.
23 Carol V. O’Shaughnessy, The Role of the Ombudsman in Assuring Quality of Residents of Long-Term Care
Facilities: Straining to Make Ends Meet, National Health Policy Forum, Background Paper No. 71, December 2, 2009.
24 National Association of State Units on Aging, Charting the Long-Term Care Ombudsman Program’s Role in a
Modernized Long-Term Care System, January, 2008.
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Older Americans Act: Long-Term Care Ombudsman Program
Lastly, the expanding role of ombudsmen in quality improvement efforts as well as assisting in
transitions from nursing homes emphasize the need for a well trained and informed ombudsman
staff. However, most ombudsmen are volunteers and ombudsman training procedures and
standards vary by state. In order for the LTC Ombudsman Program to serve as a valued resource
for outreach and referral to community services, they must be educated and informed about the
financing and delivery of long-term care services. Ombudsmen must also have well developed
communication and critical thinking skills in order to help resolve resident complaints.
Policymakers may consider establishing federal training requirements or providing technical
assistance for training, such as national or regional training institutes.
Author Contact Information
Kirsten J. Colello
Specialist in Health and Aging Policy
kcolello@crs.loc.gov, 7-7839
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