NORC at the University of Chicago Research Brief | 1 

SEPTEMBER 2019

Research Brief

Understanding the Uniqueness of the LongTerm Care Ombudsman Program within the 

Aging Services Network

Author: Kim Nguyen, PhD

NORC at the University of Chicago | 4350 East-West Highway, 8th Floor, Bethesda, MD 20814 | Office (301) 634-9300

In establishing the Long-Term Care Ombudsman program (LTCOP or Ombudsman program), the Older Americans Act (OAA or the 

Act) delineates provisions that are uncharacteristic of other OAA programs that are administered by state or territorial units on aging 

(SUAs) and area agencies on aging (AAAs). These provisions relate to independence, impartiality, and confidentiality and unify the 

LTCOP with essential standards of practice for ombudsmen in any field (such as in government, education, and business). At the 

same time, the OAA also mandates that the Ombudsman program, as well as SUAs and AAAs, share responsibility for engaging in 

systems advocacy on behalf of older adults. These programmatic similarities and differences create a distinctive dynamic between 

the LTCOP and SUAs, AAAs, and other entities with which the program coordinates to fulfill its functions. At the same time, these 

characteristics also frequently cause confusion among program partners about the LTCOP’s implementation and role in the longterm care system. To help clarify OAA provisions that are uniquely applied to the Ombudsman program, this research brief frames 

the Ombudsman program in the context of ombudsman roles more broadly, and describes its implications for program operations 

within the aging services network. 

OMBUDSMAN PROGRAM 

RESPONSIBILITIES 

In 1978, Congress established the Long-Term Care 

Ombudsman program (LTCOP or Ombudsman 

program)1 nationwide under the Older Americans Act 

(OAA, or the Act) to serve as a unique advocacy 

program for residents of long-term care facilities. Today 

the Ombudsman program is administered by the 

Administration on Aging (AoA), within the Administration 

for Community Living (ACL) of the Department of Health 

and Human Services (DHHS). Envisioned as an 

independent, person-centered consumer protection 

service, the program aims to provide a voice for longterm care residents. To fully represent residents’ 

interests and promote and protect their health, safety, 

welfare, and rights, the OAA delineates Ombudsman 

program responsibilities at both the individual and 

systems levels. At the individual level, Ombudsmen 

conduct visits to long-term care facilities and investigate 

and resolve complaints made by, or on behalf of, 

1 Note that the “O” in Ombudsman is always capitalized when referring to the Ombudsman program. References to ombudsmen in any 

field (which is touched upon in this brief) use the lower case “o.”

residents. At the systems level, Ombudsmen advocate 

for improvements in the long-term care system that 

benefit residents’ care and quality of life. These activities 

are not limited to legislative advocacy, but include 

coalition-building, speaking to the media, and other 

strategies that broadly advance residents’ rights and 

well-being. To help build capacity for both individual and 

systems advocacy efforts, the program also carries out 

education and outreach activities. These activities

include providing information and consultation to facility 

staff, residents and their families, collaborating with other 

agencies, supporting family and resident councils, 

developing citizen organizations, and empowering 

residents as well as their families and caregivers to be 

effective advocates.

Ombudsman program functions are performed by a 

State Long-Term Care Ombudsman who heads an 

Office of the State Long-Term Care Ombudsman (Office 

or Office of the STLCO) in coordination with the state or 

territorial unit on aging (SUA) in all 50 states, as well as 

the District of Columbia, Puerto Rico, and Guam. The 
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State Ombudsman is responsible for statewide program 

administration and oversight of designated 

representatives of the Office, including paid staff and 

volunteers. In federal fiscal year (FFY) 2017, 1,319 fulltime equivalent staff (FTEs) and 6,625 designated 

volunteer Ombudsmen supported the program. 

The remainder of this brief describes how the same 

standards of practice that unify the LTCOP with effective 

ombudsman programs – independence, impartiality, and 

confidentiality – simultaneously distinguish it from other 

OAA programs and services. It then describes mandates 

that apply to LTCOPs, as well as SUAs, and area 

agencies on aging (AAAs), and the implications of these 

coexisting similarities and differences for Ombudsman 

program operations. 

DISTINGUISHING PROGRAM 

CHARACTERISTICS

Fundamental to the creation of a credible and effective 

ombudsman office in any field or sector is adherence to 

three interrelated principles: independence, impartiality, 

and confidentiality.2 Exhibit 1 highlights these features of 

the Ombudsman program, as outlined in the OAA and 

clarified in the State Long-Term Care Ombudsman 

Programs Final Rule (made effective July 1, 2016). The 

table presents the OAA’s Titles (Title III, VI, and VII) and 

relevant Chapter (2, 3), their corresponding programs, 

and the state and local agencies (SUAs and AAAs) that 

administer these programs and services. An “X” 

indicates that a program or agency has a given 

characteristic or responsibility. A slash mark (“/”) 

indicates that the program or agency partially meets or 

fulfills a given characteristic or responsibility. For 

example, SUAs and AAAs serve residents of long-term 

care facilities insofar as these agencies are responsible 

for delivering home and community-based services 

(HCBS). HCBS recipients may reside in their home or 

community or in a residential setting such as an assisted 

living facility. 

As shown in Exhibit 1, the unique characteristics of the 

LTCOP are largely not present in – nor relevant to – 

other OAA programs. Title III authorizes funds for 

nutrition and supportive services (such as transportation 

and information and assistance), family caregiving 

support, and disease prevention and health promotion 

activities, while Title VI similarly authorizes grants for 

supportive and nutrition services but with a focus on 

serving older Native Americans. The types of social 

services and activities funded under these Titles intend 

to help older adults remain independent in their homes 

and communities for as long as possible. However, 

delivery of these services does not require similar 

protections of independence or impartiality. 

Title VII funds vulnerable elder rights protection activities 

under two chapters and includes the LTCOP (Title VII, 

Chapter 2) and programs aimed at preventing elder 

abuse, neglect, and exploitation (Title VII, Chapter 3). 

While both programs focus on elder rights, the goals of 

elder abuse prevention programs are to increase public 

awareness of elder abuse and coordinate activities 

between AAAs and state adult protective services (APS) 

programs. Like Title III and VI programs, however, the 

OAA does not require special provisions for 

independence, impartiality, or confidentiality to 

implement elder abuse prevention programs under Title 

VII, Chapter 3. 

Under certain conditions, however, confidentiality 

provisions apply to Title III programs, Title VII (Chapter 

3) programs, and AAAs, which will be discussed further

in the brief.

2 The American Bar Association delineated three necessary commonalities of effective ombudsman work across types and sectors, 

including independence, impartiality, and confidentiality (See 

https://www.americanbar.org/content/dam/aba/events/dispute_resolution/Newsletter%20articles/Howard_Smith_Types_of_Ombuds.aut

hcheckdam.pdf). Other membership organizations have outlined their own standards of practice for particular types of ombudsmen, 

such as the United States Ombudsman Association (traditional ombudsman), the International Ombudsman Association (organizational 

ombudsman), and the Coalition of Federal Ombudsman (federal sector ombudsman). For example, the International Ombudsman 

Association set forth four pillars for organizational ombudsmen, including independence, neutrality and impartiality, confidentiality, and 

informality (See https://www.ombudsassociation.org/assets/docs/IOA_Standards_of_Practice_Oct09.pdf). 

Understanding the Uniqueness of the Long-Term Care Ombudsman Program within the Aging Services Network
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Title, Chapter Agency

Title

III/VI*

Title VII, Chapter 3 

Elder Abuse

Title VII, Chapter 2 

LTCOP SUA AAA

Characteristics

Independence

Separate entity blank blank X blank blank

Protection from willful interference blank blank X blank blank

Impartiality

Individual and organizational conflicts of interest 

(COI) are removed or remedied 

blank blank X blank blank

Legal counsel is without COI blank blank X blank blank

Confidentiality

Stringent confidentiality provisions (not mandated 

reporters)

/ / X blank / 

Designated health oversight agency blank blank X blank blank

Responsibilities 

Serve long-term care facility residents blank blank X / / 

Represent residents’ interests blank blank X / / 

Engage in systems advocacy blank blank X X X 

Coordinate with specified entities blank blank X X X 

* Title III authorizes funds for nutrition and supportive services (such as transportation and information and assistance), family caregiving support, and

disease prevention and health promotion activities, while Title VI similarly authorizes grants for supportive and nutrition services but with a focus on

serving older Native Americans.

Note that an “X” indicates that a given program or agency has a given characteristic or responsibility. A slash mark (“/”) indicates that the program or 

agency partially meets, or fulfills a given characteristic or responsibility. 

Independence

To ensure that Ombudsman programs have autonomy, 

the OAA designs certain features to support programs’ 

ability to act independently. This includes creating the 

Office of the SLTCO as a separate entity from its host 

agency using a bifurcated structure and including 

protections from willful interference. First, the Final Rule 

clarified the OAA’s vision of program independence by

describing the Office of the State Long-Term Care 

Ombudsman as “a distinct entity, separately identifiable, 

and located within or connected to the State agency.”

Whereas other OAA programs and services are 

administered by SUAs and delivered by designated 

AAAs (or by the SUA when deemed a single planning 

and service area) in an integrated fashion, the 

Ombudsman program is established as a distinct entity 

that is independent from SUAs. Under this bifurcated 

structure, the State Ombudsman is responsible for 

overseeing the statewide program, designating 

representatives of the Office, and managing the 

program’s fiscal resources while the SUA is responsible 

for ensuring that the LTCOP has sufficient resources 

and protections to carry out its functions. SUA functions

include:

ensuring or establishing policies and procedures;

ensuring Ombudsmen have private and unimpeded 

access to residents; 

providing disclosure of information provisions; 

ensuring mechanisms to prohibit willful interference; 

ensuring freedom from individual and organizational 

conflicts of interest; and

assigning adequate legal counsel. 

This separation of responsibilities is designed to ensure 

that the Ombudsman program has the independence to 

address and represent the needs of long-term care 

residents, while allowing the program to leverage 

important resources of the aging services infrastructure 

established by the OAA. The resultant arrangement, 

however, can also appear disjointed within typical 

bureaucratic agency structures that rely on internal 

coordination and consistency to perform their functions. 

Understanding the Uniqueness of the Long-Term Care Ombudsman Program within the Aging Services Network

Exhibit 1: Characteristics and Responsibilities of OAA Programs and Agencies
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It should be noted that while the separation of the Office 

from the SUA applies to all Ombudsman programs, 

additional provisions apply to programs that are 

characterized by a decentralized structure. The OAA 

affords states broad flexibility in how to structure their 

Ombudsman programs, which can be described as 

either centralized or decentralized. In a centralized 

structure, all program staff are employees of the agency 

housing the Office of the SLTCO (or central State 

Office). Under this structure, staff typically report to the 

State Ombudsman, regardless of their physical location 

(e.g. the central State Office, or elsewhere in the state).

In a decentralized structure, the Office of the SLTCO is 

housed in a state agency or contracted entity, but local 

Ombudsman staff are employed by another contracted 

entity designated by the State Ombudsman as a local 

Ombudsman entity.

For decentralized Ombudsman programs, SUAs, in 

coordination with the State Ombudsman, are responsible

for ensuring the monitoring of local Ombudsman entities. 

This oversight includes contractual obligations as well as 

an evaluation of fulfillment of designation requirements 

of a local Ombudsman entity and the representatives of 

the Office, i.e. adherence to conflict of interest 

provisions; firewalls to protect confidentiality, etc. The 

divided authority for programmatic oversight and 

personnel management, however, can obscure lines of 

reporting and accountability for program staff as well as 

other entities with which the program coordinates or 

shares personnel. With respect to the latter, 

representatives of the Office (or local Ombudsmen staff) 

may assume other roles within the agencies that house 

their programs.3 In these instances, an Ombudsmen’s 

dual reporting duties can create confusion. Fully and 

freely representing residents, however, hinges on 

assuring program independence and clarifying role 

ambiguity.

In addition to the program’s autonomy that derives from 

its unique operational structure, the OAA requires the 

SUA to provide for sanctions for willful interference and 

retaliation that aim to safeguard the Ombudsman 

program’s authority to carry out its functions and 

responsibilities. States and territories are required to 

create these provisions not only to enable Ombudsmen 

to carry out their duties without obstruction, but also to 

protect complainants and others who work with 

Ombudsmen from retaliation and reprisal. To preserve 

the independence afforded by this unusual structure as 

well as the program’s additional safeguards, 

Ombudsmen must maintain clear communication and 

working relationships with SUAs and other agencies 

about the Ombudsman program’s mandates.

Impartiality

The second essential element of ombudsman programs 

concerns their impartiality in carrying out complaint 

investigations and inquiries. Impartiality, however, does 

not imply that an ombudsman cannot act in an advocacy 

role. Of the three main types of ombudsmen recognized 

by the American Bar Association,4 the Long-Term Care 

Ombudsman is an advocate ombudsman. By 

impartiality, Long-Term Care Ombudsmen act without 

bias when gathering the facts in a complaint 

investigation. Ombudsman programs must also act 

without conflicts of interest (COI). 

To maintain impartiality, the OAA includes stringent 

provisions for identifying and remedying or removing

perceived or actual COI with respect to (1) Ombudsmen 

and representatives of the Office, (2) host agencies that 

house the State Office or local Ombudsman entities, and 

(3) assigned legal counsel.5 Indeed, the OAA and the

Final Rule outline a long list of potential COI with respect

to the individual (as well as members of an immediate

family of the individual) involved in the appointment of an

Ombudsman or designation of a representative of the

Office as well as the organization that hosts the

Ombudsman program. With respect to individual COI,

the OAA prohibits designating individuals to represent

the Office who have:

direct involvement in the licensing or certification of a 

long-term care facility or provider of a long-term care 

service;

an ownership or investment interest in a long-term 

care facility or service;

employment or participation in the management of a 

long-term care facility or related organization, and for 

the State Ombudsman have been employed by such 

3 According to data from the process evaluation, approximately 11 percent of local Ombudsmen reported sharing their time with another 

agency. All State Ombudsmen, however, work on a full-time basis. 

4 The American Bar Association recognizes three main types of ombudsmen: classical, organizational, and advocate.

5 COI with respect to assigned legal counsel is defined by the State ethical standards governing the legal profession.

Understanding the Uniqueness of the Long-Term Care Ombudsman Program within the Aging Services Network
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a facility or organization within one year before the 

date of determination involved; 

direct or indirect receipt of remuneration under a 

compensation with an owner or operator of a longterm care facility;

management responsibility for, or operation under the 

supervision of an individual with management 

responsibility for APS; and

responsibility as a guardian or other fiduciary capacity 

for residents of long-term care facilities in which the 

Ombudsman or representative of the Office provides 

services.

With respect to organizational COI, the OAA and Final 

Rule stipulate that the SUA shall consider organizational

COI that may impact the effectiveness and credibility of 

the work of the Office and to identify programs and 

functions that may affect the loyalty, autonomy, and 

perceptions of the Ombudsman program. These 

programs and functions include: 

licensing, certifying, or surveying long-term care 

facilities; 

an association of long-term care facilities, or any other 

residential facilities for older adults;

providing long-term care services; 

providing long-term care case management; 

long-term care facility rate settings; 

providing APS services; 

responsibility for Medicaid eligibility determinations;

conducting preadmission screening for facility 

placement; or

making decisions regarding admission or discharge of 

individuals to or from such facilities.

Should any of these programs, departments, or agencies 

reside in the same host agency as the Office of the 

SLTCO or local Ombudsman entity, the Final Rule 

requires that the SUA and the State Ombudsman 

remedy or remove the COI and report the COI to the 

Assistant Secretary through the National Ombudsman 

Reporting System (NORS), the program’s administrative 

reporting system. These requirements are vital for the 

program’s credibility and aim to ensure that the State 

Ombudsman is able to “independently make 

determinations and establish positions of the Office, 

without necessarily representing the determinations or 

positions of the State agency or other agency in which 

the Office is organizationally located” [45 CFR 

§1324.11].

With respect to legal counsel, the OAA requires that the 

SUA ensure that adequate legal counsel is available and 

able – without COI – to provide the advice and 

consultation that are needed to protect the health, 

safety, welfare, and rights of residents and assist the 

Ombudsman program in performing its official duties. 

The Final Rule clarifies these requirements, stating that 

the SUA must ensure that provision of legal counsel to 

the Ombudsman program is “adequate, available, has 

competencies relevant to the legal needs of the program 

and of residents, and is without conflict of interest” as 

defined by the State ethical standards governing the 

legal profession [45 CFR § 1324.13(j)(1)(i)]. In the event 

of COI, the Final Rule specifies that “legal counsel may 

be provided by one or more entities, depending on the 

nature of the competencies and services needed and as 

necessary to avoid conflicts of interest. However, at a 

minimum, the Office shall have access to an attorney 

knowledgeable about the Federal and State laws 

protecting the rights of residents and governing long 

term care facilities” [45 CFR § 1324.13(j)(2)]. 

Identifying, removing, or remedying COI, however, is 

becoming increasingly challenging as more states move 

to redesign their long-term care systems by adding or 

consolidating responsibilities for home and communitybased services to balance or maximize resources. When 

an agency oversees all or most long-term care 

resources, it increases opportunities for possible or 

actual COI with the Ombudsman program. For example, 

if an AAA hosts a local Ombudsman entity and provides 

long-term care case management services, a COI arises 

if a resident presents a grievance to an Ombudsman 

about an AAA case manager upon whom the resident 

depends to arrange in-home services. 

Turning to potential COI related to legal counsel, the 

SUA may assign the Office of the Attorney General (AG) 

as the primary legal counsel to all the agencies it 

houses. Under this arrangement, COI may occur in a 

dispute if the AG represents both the Ombudsman 

program and another agency (e.g., APS, licensing and 

certification) that is co-located within the state agency. 

Given the AG’s competing allegiances, a conflict may 

result when legal counsel is constrained from fully 

representing the Ombudsman program because of its 

multiple responsibilities or interests to the state or other 

agencies. However, the OAA is clear on this matter. It 

stipulates that adequate legal counsel must “provide 

advice and consultation needed to protect the health, 

safety, welfare, and rights of residents” and to “assist the 

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Ombudsman and representatives of the Office in the 

performance of the official duties of the Ombudsman and 

representatives” [Section 712 (g)(1)(A)(i)(ii)].

Confidentiality and Disclosure

Provisions regarding resident-identifying 

information. The Ombudsman program is designed to 

represent the interests of the resident (and not 

necessarily the interests of the State) and to support 

residents’ informed decision making about disclosure of 

his or her confidential information. These disclosure 

provisions must be followed for Ombudsman programs 

to effectively support the resident and their wishes as 

they relate to handling sensitive information. For these 

reasons, the OAA and Final Rule outline stringent 

disclosure provisions that prohibit the Ombudsman 

program from sharing identifying information about 

residents or complainants to any individual or entity 

unless the resident’s consent is obtained (see text box). 

Other agencies may routinely share information about 

beneficiaries that they serve, sometimes creating 

expectations that the LTCOP can or should do the same. 

As a result, Ombudsmen must explain to others that the

Ombudsman program’s confidentiality provisions prevent 

disclosure of identifying information. 

For other OAA programs, stringent confidentiality 

provisions apply to in-home services for frail older 

individuals as well as programs for preventing elder 

abuse, neglect, and exploitation. To protect the rights of 

frail older adults and victims of abuse, neglect, and 

exploitation who receive services, the Act preserves the 

confidentiality of their records, limiting the disclosure of 

information, as needed. In addition, the Act requires 

AAAs to ensure that service providers protect the privacy 

and confidentiality of service recipients with respect to 

the declaration or non-declaration of their income as well 

as any contributions. 

Access to facilities, residents, and resident records. 

The OAA grants authority to the Ombudsman program to 

have “private and unimpeded access to long-term care 

facilities and residents” as well as access to “files, 

records, and other information concerning a resident” 

[Section 712 (b)(1)(A-B)]. To facilitate Ombudsmen’s 

access to residents’ individually identifiable health 

information, the OAA considers the LTCOP to be a 

health oversight agency. This designation precludes 

long-term care facilities from withholding resident 

information that is necessary for an Ombudsman’s 

investigation. Without its commitment to confidentiality, 

the LTCOP would not be able to gain the trust that is 

necessary for residents to safely voice concerns, nor 

would the program be able to obtain vital information for 

the investigation and resolution of complaints.

As shown in Exhibit 1, the Ombudsman program is the 

only OAA program that focuses solely on addressing the

The OAA prohibits disclosure of the identity of the 

complainant or resident unless the complainant or 

resident or legal representative consents or 

disclosure is required by court order. The 

Ombudsman “may disclose information as needed in 

order to best serve residents with limited or no 

decision making capacity, who have no known legal 

representatives and are unable to communicate 

consent, in order for the Ombudsman to carry out the 

functions and duties described” [Section 712 

(d)(2)(C)].

The Final Rule prohibits the Ombudsman or 

representatives of the Office from reporting 

suspected abuse, neglect or exploitation of a resident 

without informed consent, notwithstanding State laws 

to the contrary [45 CFR 1324.19(b)(3)(iii)]. The 

regulation’s preamble also addresses the 

Congressional intent “for the Ombudsman program to 

be a safe place for the concerns of residents to be 

brought, knowing that their information will not be 

disclosed without their consent...” Fed. Reg.Vol. 80, 

No.28 / 7732.

SIMILAR PROGRAM 

RESPONSIBILITIES 

In the following section, we discuss key functions of the 

Ombudsman program that are similar to those carried 

out by SUAs and AAAs (while also noting key 

differences from other OAA programs). We also discuss 

how the populations and interests served by the 

Ombudsman program affect the responsibilities that it 

shares with SUAs and AAAs.

Serve Long-Term Care Facility Residents

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needs of residents of long-term care facilities.

6 All other 

programs and services funded under the OAA target 

older adults in their homes and communities. 

Furthermore, because of the size of the population that

Title III programs serve, they typically receive the largest 

share of OAA funding, compared to other programs. In 

FFY 2019, the OAA allocated 72.9% of funds to Title III 

programs while Title VI programs received 2.2 percent, 

and Title VII programs were funded at 1.1 percent (78% 

of which was directed to the LTCOP). The Ombudsman 

program’s small size relative to other OAA programs as 

well as its unique target population can create 

challenges in communicating the program’s role in the 

long-term care system. 

In terms of the distribution of federal funding, ACL 

allocates federal funds authorized under OAA statutory 

funding formulas to SUAs. Funds for Titles III & VII are 

allocated to states based on a state’s share of the adult 

population that is 60 years of age or older. For Title VI 

programs, tribes can define their age group to include 

those under 60 years of age and must apply for funding. 

Whereas OAA programs are funded based on age of the 

population that their programs serve, the Ombudsman 

program serves all residents of long-term care facilities, 

regardless of age. Consequently, current formulas for 

distributing funds can underestimate the funds needed 

for the LTCOP to serve their target population.

With respect to service population, SUAs and AAAs 

serve long-term care residents to the extent that their 

states participate in and deliver HCBS programs. The 

array of HCBS that states provide includes supports and 

services for individuals living in their own homes and 

communities outside of facilities as well as for services

(such as transportation or case management) in 

residential settings – some of which are included under 

board and care homes to which the Ombudsman 

program provides advocacy services. Overlap with the 

population that the Ombudsman program serves can 

create COI linked to organizational location that were 

described earlier in this brief. 

Represent Residents’ Interests

As delineated in the OAA, the Ombudsman program 

represents the interests of long-term care residents, not 

the State or the aging services network. In this role, the 

Ombudsman program is the only OAA program that has 

direct, unimpeded access to residents. Insofar as SUAs 

and AAAs support or coordinate with the LTCOP, these 

agencies also represent residents’ interests. However, 

serving as the voice of residents and advocating on their 

behalf can create vulnerabilities and tension when 

Ombudsmen take a public policy position that does not 

align with the SUA, AAA, or other state agency. This is 

particularly true with respect to the program’s public 

policy advocacy function (discussed below).

Engage in Systems Advocacy

The OAA established clear mandates for the aging 

services network to advocate on behalf of older adults, 

but it does not apply these mandates across all 

programs. Instead, the OAA empowers SUAs, AAAs, 

and the Ombudsman program to engage in systems 

advocacy. SUAs are charged with reviewing and 

commenting on State plans, budgets, and policies which 

affect older individuals and providing technical 

assistance to any entity or individual representing their 

needs. AAAs are mandated to advocate for older adults 

in the community by monitoring, evaluating, and 

commenting upon policies, programs, hearings, levies, 

and community actions which will affect them. The only 

OAA program that is also responsible for systems 

advocacy is the Ombudsman program. This charge is 

consistent with ombudsman programs of all types which 

have historically functioned under a dual mandate: 

investigate and resolve complaints, and identify trends 

and address systemic issues to prevent issues from 

recurring.7 The Ombudsman program shares this 

micro/macro focus in carrying out individual and systems 

advocacy. By contrast, other OAA programs provide, or 

are responsible for providing, direct services to 

individuals but they lack additional responsibilities to 

promote system-level improvements in the services they 

deliver. Although SUAs and AAAs have a general 

mandate to advocate on behalf of older adults, their 

overarching responsibility is the provision of services. 

Whereas systems advocacy is one of many functions of 

SUAs and AAAs, systems advocacy is a primary charge

of Ombudsman programs. According to the Act, 

Ombudsman programs are required to (1) represent 

6 In 16 states and DC, LTCOPs have the ability to provide in-home services, but these mandates are funded at the state rather than 

federal level.

7 Gadlin, Howard and Samantha Levine. 2008. “Stranger in a Strange World: The Ombudsman in the Federal Government.” 

ACResolution, Spring.

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residents’ interests before governmental agencies and 

pursue administrative, legal, and other appropriate 

remedies; (2) analyze, comment on, and monitor the 

development and implementation of federal, state, and 

local laws, regulations, and other governmental policies 

and actions relating to the adequacy of long-term care 

facilities and services; (3) make recommendations 

regarding these laws, regulations, policies, and actions; 

and (4) facilitate public comment on the laws, 

regulations, policies, and actions that pertain to 

residents’ health, safety, welfare, and rights. 

Tensions may arise when the Ombudsman program 

advocates for a policy or action that may support 

resident care, rights or consumer protections that may in 

some way be contrary to the position of their host 

agency. For example, Ombudsman advocacy for 

increased caregiver training hours may strain the budget 

of the state and AAAs. By advocating for the 

development and implementation of laws, regulations, 

and administrative action on behalf of residents’ interests

– even when they differ from the policies and positions of

the agency where the program is located – the

Ombudsman program is fulfilling its mandated advocacy

function. This inherent tension can create

misunderstandings among agencies, state and local

government, and the LTCOP. Such misperceptions are

less common when there is a clear understanding and

acceptance by all parties of the program’s mandate to

serve as the independent voice of long-term care

residents.

Coordinate with Specified Entities

As administrators of OAA programs, SUAs and AAAs 

are charged with coordinating with an array of providers 

to deliver services to older adults. The coordination 

requirement of SUAs and AAAs is also shared by the 

Ombudsman program.8 The OAA identified four entities 

with which the Ombudsman program is required to 

coordinate services: protection and advocacy (P&A) 

systems, legal assistance, State and local law 

enforcement agencies, and courts of competent 

jurisdiction. More recently, the Final Rule enumerated six 

additional entities with which coordination is mandated 

given their relevance to the health, safety, well-being, 

and rights of long-term care residents. These entities 

include AAAs, Aging and Disability Resource Centers 

(ADRCs), APS programs, facility and long-term care 

provider licensure and certification programs, the State 

Medicaid fraud control unit, and victim assistance 

programs. 

The Ombudsman program’s coordination with other 

entities is intended to enhance the program’s capacity to 

conduct individual and systems advocacy. While the 

program engages with a wide and diverse range of 

entities to perform these functions – often well beyond 

those enumerated in the OAA and Final Rule – the 

program’s relationship with monitoring and enforcement 

agencies is noteworthy. The Ombudsman program’s 

approach is distinct from, and designed to complement

the work of facility and long-term care provider licensure 

and certification programs. In contrast to the work of 

federal and state surveyors, the Ombudsman program 

does not have enforcement or regulatory oversight 

authority and consequently, is unable to sanction 

facilities for poor performance. Instead, the program 

complements the work of surveyors to address quality of 

care in long-term care facilities through complaint 

resolution on an informal level and providing a regular

and unannounced presence in nursing homes and board 

and care homes. As an alternative dispute resolution 

method, the Ombudsman program supplements formal 

channels that are already in place. By offering informal 

options for addressing concerns, complainants who are 

hesitant to use formal mechanisms (for fear of reprisals 

or other reasons) may be more likely to come forward. 

These complaints may otherwise go unreported and 

their successful resolution can ultimately prevent 

problems from rising to the need for formal intervention. 

Summary

In establishing the Ombudsman program within the 

aging services network, the OAA envisioned that the 

program would have the same characteristics as 

effective ombudsman offices in any field (whether it be 

government, education, or business, etc.). The typical 

characteristics necessary for the credibility, conduct, and 

effective functioning of ombudsman programs – 

independence, impartiality, and confidentiality – 

however, make the LTCOP unique in the context of its 

8 On behalf of Title VII’s elder abuse prevention programs, SUAs are charged with working with eight specified entities to foster a 

coordinated, multidisciplinary response to elder abuse, neglect, and exploitation. The program itself, however, is not tasked with this 

function.

Understanding the Uniqueness of the Long-Term Care Ombudsman Program within the Aging Services Network
NORC at the University of Chicago Research Brief | 9

role as an aging services program.

9 At the same time,

the Ombudsman program shares similar mandates with 

SUAs and AAAs to the extent that they all engage in 

systems advocacy and collaborate with other entities on 

behalf of older adults. Confusion about the LTCOP’s 

implementation and responsibilities have long persisted 

because of its differences from other OAA programs as 

well as its similarities with SUAs and AAAs. While the

LTCOP’s distinctiveness from other OAA programs is a 

recurring source of confusion for stakeholders in the 

aging services network, the similarities of the program’s 

responsibilities with SUAs and AAAs (e.g., systems 

advocacy mandate) can create tension. Clear

communication about the program’s unique role and 

value to the aging services network – particularly as a 

vigorous complement to enforcement mechanisms that 

address quality of care in long-term care facilities – is 

needed to minimize misunderstandings and tension 

about the program’s function and mandated 

responsibilities. Part of that effort means understanding 

the LTCOP within the framework of ombudsman 

programs more broadly. That is, as in any field wherein 

an ombudsman operates, only with independence, 

impartiality, and confidentiality can Long-Term Care 

Ombudsman programs effectively address individual

resident concerns, but also the larger long-term care 

system that gives rise to it.

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effective solutions.

9 Although other OAA programs and services also have unique characteristics, those characteristics do not necessarily pertain to 

stringent provisions that create interagency misunderstandings and tension in carrying out mandated functions.

Understanding the Uniqueness of the Long-Term Care Ombudsman Program within the Aging Services Network