Long-Term Care: Information on the Ombudsman Program

What GAO Found

The Long-Term Care (LTC) Ombudsman Program is an independent, consumer protection service focused on protecting the health, safety, welfare, and rights of LTC residents. The program has a unique role in that it represents the interests of residents rather than those of the state and has a public policy advocacy function. The Administration for Community Living (ACL) within the Department of Health and Human Services administers the program. All 50 states, as well as the District of Columbia, Puerto Rico, and Guam, have an Office of the State LTC Ombudsman, headed by a full-time state LTC ombudsman.

State LTC ombudsman programs are responsible for serving individuals of any age who reside in LTC facilities. These LTC facilities may include nursing homes and certain residential care communities, such as assisted living facilities and adult foster homes. In fiscal year 2022, state LTC ombudsman programs were responsible for serving more than 3 million residents across approximately 76,000 LTC facilities, according to data from ACL. In fiscal year 2022, total expenditures for the state LTC ombudsman programs were about $140 million with about 49 percent coming from federal sources.

State LTC ombudsman programs provide several services including conducting regular facility visits; identifying, investigating, and resolving complaints; providing information and support to residents, and others; and conducting systems advocacy. These programs do not provide direct care to residents. Most programs used a combination of paid staff and volunteers to provide such services in fiscal year 2022—the most current year available—with volunteers donating approximately 1 hour per week.

Officials we interviewed from five selected state LTC ombudsman programs, ACL, and stakeholders described various challenges that make it difficult to provide all the services they are responsible for providing. Examples of commonly reported challenges include the following.

• Ombudsmen work and resident needs have become increasingly complex which can require more or different types of resources. For example, officials from two states told us ombudsmen are increasingly serving residents with complex needs related to mental health, substance misuse, or cognitive impairment.
• Increase in the number of assisted living facilities and the resulting workload for ombudsmen.
• Resource limitations that have made it challenging to meet workload demands or hire necessary staff, including funding and staffing limitations.

Officials from the five selected states also reported that the COVID-19 pandemic introduced challenges for their programs related to staffing, funding, or quality of care. Officials from four of these states also reported that the pandemic provided opportunities to enhance their programs, such as increased use of virtual tools to connect with residents and enhance communication. At the national level, ACL data showed that the COVID-19 pandemic affected the workload of and staffing for state LTC ombudsman programs.

• The workload of state LTC ombudsman programs generally declined during the first year of the pandemic and partially rebounded to pre-pandemic levels in fiscal year 2022.
• The volume of paid staff declined between fiscal years 2019 and 2020 but quickly rebounded to about pre-pandemic levels in fiscal year 2021. However, the number of volunteers has consistently declined since fiscal year 2019.

Why GAO Did This Study

The residents of LTC settings are often vulnerable individuals in need of high-quality care from the nursing home, assisted living, or other care setting where they live. According to ACL, the number of individuals in LTC facilities is expected to increase significantly given the growth in the aging population. We were asked to review the LTC Ombudsman Program. This report describes how workload and staffing of state LTC ombudsman programs have changed in recent years and reported challenges these programs face in providing services.

To obtain information on the LTC Ombudsman Program, including information on the funding, organization, and states' ability to provide the necessary services, we reviewed information from federal and state sources. We collected and reviewed data from ACL's National Ombudsman Reporting System—a system that compiles national statistics reported by states about ombudsman activities—for fiscal years 2019 through 2022, the most recent 4-year period available. We also interviewed officials from ACL, five state LTC ombudsman programs (Arkansas, Connecticut, Montana, Ohio, and Oregon), and four national stakeholder organizations, such as the National Association of State Long-Term Care Ombudsmen Programs.

For more information, contact John E. Dicken at (202) 512-7114 or DickenJ@gao.gov.