NORC at the University of Chicago Research Brief | 1 

SEPTEMBER 2019

Research Brief

Strengthening the Aging and Disability 

Networks: Promising Practices of Long-Term 

Care Ombudsman Programs

Authors: Kim Nguyen, PhD, Emily White, MA, and Jennifer Scolese, MPP

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

This research brief highlights examples of promising practices that Long-Term Care Ombudsman programs are undertaking to 

strengthen program operations and improve the quality of life and care of long-term care residents. While not exhaustive, the 

selection is intended to reflect the range of activities that Ombudsman programs carry out, including education/outreach, individual 

advocacy, systems advocacy, and program quality assurance. Based on a preliminary review, these activities show potential to 

improve processes or outcomes for consumers and stakeholders that may be of interest to other programs for adoption. Findings 

presented in this brief are drawn from multiple data sources. These include data that were collected as part of the Process 

Evaluation and Special Studies Related to the Long-Term Care Ombudsman Program conducted by NORC at the University of 

Chicago (NORC) on behalf of the Administration for Community Living (ACL); narrative data from the National Ombudsman 

Reporting System (NORS; the program’s administrative reporting tool); and The National Consumer Voice for Quality Long-Term 

Care Conference in 2018. 

EDUCATION FOR PROSPECTIVE CONSUMERS: 

HELPING CONSUMERS FIND THE RIGHT FACILITY 

Educating Prospective Residents and Families. The Illinois State Ombudsman 

program has worked since 2015 with their state’s information technology (IT) department 

to develop the Illinois Department on Aging Ombudsman Consumer Choice Search, a 

website that enables consumers and families to search for licensed long-term care 

facilities based on their particular needs and preferences. Prior to that time, consumer 

requests for information about facility services were not publicly available. With the 

development of the website, consumers can search facilities based on location, services 

provided, and populations served. 

The Consumer Choice Search website was made possible through the Illinois General 

Assembly’s 2008 passage of the Residents’ Right to Know Act, P.A. 95-0823, that 

requires the state’s long-term care facilities to complete the Consumer Choice 

Information Report questionnaire on an annual basis. Developed in collaboration with the 

Illinois Attorney General’s Office, the Illinois Department on Aging (including the Illinois 

Ombudsman program), long-term care professional associations, and advocacy 

organizations, the Consumer Choice Information Report contains information about 

facility services; special services and amenities; facility and resident profiles; meals and 

nutrition; rooms/apartments, furnishing and equipment; family, volunteer, and visitation 

provisions; safety and security; staffing; and ownership and administration. These data 

are used to populate the website. Although all long-term care facilities are listed on the 

website, only those that have completed the questionnaire have their information posted. 

The Illinois program continues to encourage the remaining facilities to participate. 

Resource

Consumer Choice Search: 

https://webapps.illinois.

gov/AGE/Ombudsman

Search
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EDUCATION FOR RESIDENTS AND INDIVIDUAL 

ADVOCACY: MAKING IT EASIER FOR CONSUMERS 

TO UNDERSTAND AND PROTECT THEIR RIGHTS 

Educating and Empowering Residents Living in Residential Care Homes. As 

community-based residential options continue to grow in popularity, Ombudsman 

programs are working to ensure that residents of these communities understand their 

rights. In partnership with Connecticut Legal Services, Inc., the Connecticut Ombudsman 

program developed a Residential Care Home (RCH) Tool Kit in 2016. The tool kit 

provides residents with information about their rights, steps to advocate on their own 

behalf, and resources that they can access. The tool kit covers a broad range of resident 

rights, including those related to quality of life, finances, privacy, personal property, 

visitation, community, physical surroundings, choice of physician, room-to-room transfers, 

emergency transfers, discharge, and readmission. For each topic, a “house rule” that 

residents may hear from facility staff is presented (e.g., “We are not responsible for any 

of your personal property that is missing or taken.”). Citing relevant state statutes, the 

house rule is followed by a description of resident rights that dispels the given house rule. 

Should a resident believe that their rights have been violated after having received 

education on the facts, the tool kit advises residents on steps to take to protect their 

rights. The resource also includes information about home and community-based 

services, resident councils, a complaint form, a personal belongings inventory list, and 

contact information for legal services and other helpful resources. 

Empowering Residents to Self-Advocate and Empower Others. In 2002, the 

Pennsylvania Ombudsman program initiated the Pennsylvania Empowered Expert 

Residents (PEER) program to encourage partnerships among residents, facility staff, and 

local Ombudsmen to address resident concerns before they become more serious 

problems. Developed in response to residents who said, “I want to be an Ombudsman,” 

the PEER program helps residents donate their time and expertise to address issues that 

will resonate with peers. The program offers five two-hour empowerment training 

sessions that train residents to self-advocate and empower fellow residents to improve 

their care and quality of life in long-term care facilities. A two-hour session is also 

delivered to facility staff to orient them to the PEER concept. Open to all residents of 

nursing homes, personal care and assisted living homes, and other adult daily living 

centers, participating residents not only support their own communities, but are also 

connected to PEERs statewide. Since the program’s inception, over 2,600 residents in 

more than 225 facilities have completed the training. 

Residents who complete the program are invited to attend a graduation ceremony and 

receive a certificate. In some participating facilities, the State Ombudsman observed that 

complaints increased because residents became aware that they could report

complaints. To confirm these observations and other anecdotal evidence supporting the 

program’s success, the Pennsylvania State Ombudsman intends to contract with an 

evaluator to assess whether the PEER program has been effective.

Resource

Residential Care Home Tool 

Kit:

https://ltcombudsman.org/up

loads/files/support/cttoolkit.PDF

Resource

PEER Brochure: 

https://www.swpaaaa.org/pdfs/PEER%20broc

hure.pdf
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EDUCATION FOR FACILITY STAFF: SUPPORTS TO 

INCREASE STAFF ENGAGEMENT AND PERSON 

CENTERED CARE

Engaging Facility Staff in Effective Staff Practices and Person-Centered Care. 

Although adequate numbers of well-trained staff are fundamental to high-quality resident 

care, staffing shortages due to high vacancy and turnover continue to impede the ability 

of many long-term care facilities to meet residents’ needs. To help recruit and retain paid 

caregivers (known as state-tested nurse aides, or STNAs, in Ohio) in nursing homes, 

Ohio’s Office of the State Long-Term Care Ombudsman sought to bolster a key reason 

that STNAs report staying committed to their work – a sense of feeling valued that is 

derived from positive relationships with residents for whom they care. Building on the 

Pioneer Network’s Engaging Staff in Individualizing Care starter tool kit, the Ohio 

Ombudsman program, in partnership with B&F Consulting, implemented the PersonCentered Staff Engagement Project. Funded with Civil Monetary Penalty funds, the grant 

project aimed to increase staff engagement through person-centered care and help build 

an infrastructure at facilities that promotes communication and teamwork. Between June 

2017 and March 2019, the project advanced two practices that the Pioneer Network 

project found improved clinical, staff, and organizational outcomes: (1) 15 minute daily 

huddles among staff about the status of current and new residents, and (2) consistent 

assignment of staff to the same residents to strengthen relationships between STNAs 

and residents as well as STNAs’ familiarity with residents’ preferences. 

To implement the project, B&F Consulting led the statewide learning collaborative and 

Ombudsman liaisons in each of the 12 Ohio regions provided technical support to the 

129 facilities that participated in the project. These efforts included leading workgroups 

and providing individual consultation and coaching to facility staff. In addition, the Ohio 

Ombudsman program contracted with Scripps Gerontology Center at Miami University of 

Ohio to evaluate the project with the ultimate goal of replicating it throughout the state. 

Study findings showed that compared to non-participating facilities, those that 

participated in the intervention had positive and significant changes in staff 

communication and person-centered care practices. For example, more nurses and 

STNAs engaged in care planning and received information about new residents in a 

timely manner. Various groups of staff participated in huddles for the first time, and 

huddles occurred more frequently and among more staff than before the program was 

implemented. Person-centered care improved in 14 of the 16 areas that were measured, 

with the greatest improvements observed in residents deciding when to eat, staff having 

the time to learn about residents’ histories, having supervisors that consider staff 

preferences when making care decisions, and having enough time to allow residents to 

do things for themselves. Another benefit of the project included expertise developed 

within Ohio Ombudsman program that could be used to provide information and ongoing 

assistance to homes.

Acknowledging and Understanding Residents’ Fears of Retaliation. Prompted by 

findings from the 2005 VOICES Forum1 about residents’ fear of retaliation, the 

Connecticut Ombudsman program initiated a statewide work group and commissioned 

the University of Connecticut Health Center to study retaliation among residents in skilled 

nursing facilities. The study found that fear of retaliation is a reality for residents in 

 

1 The VOICES Forum is a statewide annual event that offers an opportunity for resident counsel 

presidents, legislators, and other public officials to engage and identify the most pressing issues facing 

Connecticut nursing home residents.

Resource

Scripps Gerontology 

Center’s Evaluation Report: 

https://sc.lib.miamioh.edu/bit

stream/handle/2374.MIA/65

36/straker-person-centeredstaff-engagement-projectevaluation-9-10-19-

bt.pdf?sequence=1&isAllow

ed=y

Ohio Ombudsman Program 

Proposal: 

https://medicaid.ohio.gov/Po

rtals/0/Resources/CMP/Staff

EngagementProjectProposal

.pdf

Pioneer Network’s Starter 

Toolkit for Engaging Staff in 

Individualizing Care: 

https://www.pioneernetwork.

net/resourcelibrary/resourcelibraryengaging-staffindividualizing-care/
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various supportive housing situations. As one component of a larger awareness initiative, 

the Connecticut Ombudsman program developed a Voices Speak Out Against Retaliation

training video to bring attention to the issue. The curriculum aims to help facility staff be 

conscious of how their behaviors are perceived by others and may be unintentionally 

viewed as retaliatory. The training is also designed to encourage residents to voice their 

concerns or address them through available resources (e.g., resident council, 

Ombudsman program, social worker, etc.) as well as encourage visitors to raise concerns 

to appropriate staff. The instructor’s guide includes information on the history of the 

project, definitions of retaliation and fear of retaliation that were developed by the 

workgroup, a list of required materials (e.g., video monitor or laptop), video highlights, 

facilitation tips, a step-by-step guide on organizing the session and facilitating the 

discussion, and handouts (pre-activity questions about participants’ perceptions of 

retaliation and video discussion questions). After piloting the curriculum in several nursing 

homes, the State Ombudsman reported that the training was well-received by staff. Other

state Ombudsman programs and higher education programs have requested to use the 

curriculum for their own trainings. 

SYSTEMS ADVOCACY: OVERSIGHT MECHANISMS 

TO ENSURE CONTINUITY OF SERVICE

Anticipating Harm to Residents’ Welfare and Safety with Third-Party Notification of 

Utility Disconnection. Facilities that are resource-constrained not only place their 

financial viability at risk, but also residents’ safety and well-being. The Office of the 

District of Columbia (DC) Long-Term Care Ombudsman identified a facility’s inability to 

make timely payments on utility bills as a critical sign that it may be struggling financially. 

In the past, the DC Ombudsman program observed these issues with some smaller 

facilities, particularly community residential facilities (CRF). In at least one instance, a 

CRF’s gas service was shut off during the winter months due to non-payment. 

Termination of gas service meant no stove cooking, hot water for bathing, or heat. The 

facility was using portable heaters that posed a potential fire hazard. Given the impact of 

terminating utility services on residents’ welfare and safety, the State Ombudsman 

coordinated with the District’s Office of the People’s Counsel (which represents utility 

customers) and utility companies serving the District to develop a ‘Third-Party Notice of 

Utility Disconnection’ bill. This legislation requires a number of changes to the latepayment notification process. Under the new law, utility companies are responsible for 

implementing the notification program while facilities are required to enroll in the program 

and designate their regulatory agency as its third party contact. This authorizes the 

regulatory agency to receive a duplicate notification of any termination of service. The 

regulatory agency then forwards the notification to the State Ombudsman so the program 

can represent the residents’ interests and protect their health, safety, and welfare. This 

law, officially titled the Community Residential Facilities Third-Party Notice of Utility 

Disconnection Requirement Act of 2018 [D.C. Law 22-104], was passed in 2018.

Enhancing Services for Residents with Alzheimer’s Disease and Related 

Dementias. Recognizing the need to better serve residents with Alzheimer’s disease and 

related dementias, the Oregon Ombudsman program implemented the Memory Care 

Initiative in 2016. A review of internal data revealed that significantly fewer requests for

Ombudsman assistance from residents and their family members were generated from 

regular visits to memory care settings. Until that time, the minimal data collected on 

Resource

Voices Speak Out Against 

Retaliation Training Guide: 

https://www.ct.gov/ltcop/cw

p/view.asp?Q=473774&A=3

821

Resource

Legislative Code: 

https://code.dccouncil.us/dc/

council/laws/22-104.html
Strengthening the Aging and Disability Networks: Promising Practices of Long-Term Care Ombudsman Programs

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memory care settings prevented an informed enhancement of Ombudsman services in 

these settings. 

To improve advocacy on behalf of residents who are unable to fully communicate their 

needs and concerns, the Oregon Ombudsman program focused the initiative’s efforts on 

having volunteer Ombudsmen collect data on their observations when visiting memory 

care settings and providing them with additional training on key topics. This included an 

overview of memory care endorsed facilities; best practices in memory care; the role of 

the memory care administrator; observation techniques; requirements for staffing and 

meal and food times; recognizing chemical restraints; and working with families, including 

establishing family councils. More than 30 Ombudsmen who completed the training were 

designated as Memory Care Specialists (MCSs). These MCSs visited their assigned 

facility at least weekly for six months, varying their visitation times, and completed a 

report after each visit. MCSs also agreed to participate in the same training program that 

facility staff in their memory care attend. Of the 185 memory care units operating in the 

state of Oregon, 45 (or 24%) of memory care units had an assigned MCS for the 

purposes of this study. 

During visits, the MCSs observed a number of issues in memory care units such as 

staffing shortages and limited staff interactions with residents, inadequate meal time 

procedures (e.g., excessive wait times or lack of appropriate silverware), and absence of 

meaningful activities, particularly in facilities where an Activities Director position was 

vacant. To supplement these findings and better understand the challenges in memory 

care settings, the State Office reviewed facility incident reports and redacted investigation 

reports from Adult Protective Services (APS). The Ombudsman program compiled its 

findings in a report that was developed in 2017 and continues to use these findings to 

inform program practices. This includes an increased focus on memory care related 

consumer education, improving training for certified volunteer Ombudsmen serving 

memory care settings, and continuing efforts with legislative partners and stakeholders to 

address the concerns of residents in specialized memory care settings. 

Interagency Efforts to Challenge Facility-Initiated Discharges and Transfers. Based 

on a review of involuntary discharge notices received (a requirement in Maryland since 

1995), the Maryland Ombudsman program observed a sharp increase in involuntary 

discharge notices from a single private nursing home corporation. Although the company 

operated only five nursing homes with 782 beds in Maryland (representing less than 

three percent of all nursing home beds in Maryland), these facilities accounted for 

approximately 67% of the state’s involuntary discharges between January 2015 and May 

2016. In May of 2015, the State Ombudsman as well as local Ombudsmen met with the 

provider in an attempt to resolve the issue, highlight the importance of adequate 

discharge planning, and encourage the provider to assist residents and families with 

understanding payment options, including Medicaid and how to apply for it. After no 

improvements were observed, the State Ombudsman sought assistance from the Office 

of the Attorney General (OAG) to address the provider’s discharge practices. In May of 

2016, the OAG initiated a civil investigation under the Maryland False Health Claims Act, 

including pre-dispute litigation requests. The investigation included reviews of deficiency 

statements, interviews with evicted residents and their family members, a statewide 

review of the involuntary discharge notices, and an analysis of length-of-stay data using 

the Minimum Data Set.2 The investigation yielded numerous examples of inappropriate 

discharges of vulnerable residents to homeless shelters (both in and out of state), motels, 

 

2 The Minimum Data Set (MDS) is a health status and screening tool used for all residents of Medicare 

and Medicaid certified nursing homes.

Resource

Summary of Findings from

Oregon’s Memory Care 

Initiative: 

https://assets.websitefiles.com/594add07a0707c

3191615e9f/5bc12f9c05f21

2f64a95848b_Memory%20

Care%20in%20Oregon.pdf

Resource

Presentation Slides from 

The National Consumer 

Voice for Quality LongTerm Care Conference:

https://theconsumervoice.or

g/2018-

conference/conferencematerials

Court Filing: 

http://www.marylandattorne

ygeneral.gov/News%20Doc

uments/State_v_NMS_Co

mplaint.pdf
Strengthening the Aging and Disability Networks: Promising Practices of Long-Term Care Ombudsman Programs

NORC at the University of Chicago Research Brief | 6

and “predatory” unlicensed personal care homes, as well as multiple evictions of 

residents with mental illness or intellectual disabilities. In December of 2016, the OAG 

filed a suit in circuit court against the provider, alleging it had engaged in unfair, unsafe, 

and unlawful discharge practices in violation of the Patient’s Bill of Rights (a Maryland law 

that protects nursing home residents) and that it submitted false claims to the State’s 

Medicaid program. The OAG complaint also alleged that the provider identified residents 

for eviction based on the source of their public health insurance (replacing Medicaid longterm care recipients with prospective residents who are covered by Medicare). After the 

filing, one of the company’s nursing homes closed and another provider organization 

assumed responsibility for the remaining facilities. In October of 2018, the provider 

settled with the State, agreeing to cease operating nursing facilities and pay $2.2 million 

to the State. 

Legislative Session Bill Tracking. To monitor the development and implementation of 

proposed state laws related to long-term care supports and services including licensed 

facilities, the Washington State Ombudsman program developed a legislative bill tracking 

system to inform stakeholders about long-term care legislation in the state. Proposed bills 

are monitored and tracked each day. The online tracking system includes a link to the 

proposed bill, the subject of the bill, the name of the sponsor, the Ombudsman program’s 

position on the bill, comments (such as links to companion bills), and the bill’s current 

status. Consumers, advocates, and stakeholders may also elect to receive daily updates 

of these bills during the legislative session. 

STRENGTHENING PROGRAM OPERATIONS: 

NEW PROCESSES AND APPROACHES

Managing Involuntary Discharge Notifications. In September of 2016, the Center for 

Medicare & Medicaid Services (CMS) issued the “Medicare and Medicaid Programs; 

Reform of Requirements for Long-Term Care Facilities.” One requirement stipulated that 

nursing homes send discharge and transfer notices to Ombudsman programs. Because 

the regulation did not specify whether notification was limited to involuntary discharges, 

facility staff widely interpreted this requirement to include all transfers and discharges, 

regardless of reason. This resulted in an influx of notices received by many Ombudsman 

programs (particularly in those states that did not already have state notification 

requirements), diverting staff attention to managing the flood of paperwork. 

CMS later issued a clarification that only notices of involuntary (or facility-initiated) 

transfers or discharges must be provided. Despite this clarification, some Ombudsmen 

reported continuing to receive large numbers of unnecessary notifications and working 

with facility staff to promote understanding of these requirements and reduce 

unnecessary work for both nursing homes and the Ombudsman program. Given the 

influx of notices, some State Ombudsmen developed new processes and tools to handle 

the tremendous increase in discharge notices and provide training and education to 

nursing home facility staff on the requirements under the new regulations.

Database Tracking. In Michigan, the Ombudsman program developed a database to 

track involuntary discharge notifications. The database is used to guide program activities 

in specific locations, identify potential triggers that may lead to a facility’s closure, 

examine trends that may be statewide or specific to a region or provider group, and 

highlight possible concerns that should be brought to the attention of the state agency or 

the state Medicaid agency. 

Resource

Legislative Bill Tracking 

System: 

https://www.waombudsman

.org/news/2016-legislativebill-tracking/
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Offering Additional Submission Options. In North Dakota, the State Ombudsman 

developed a protocol for nursing homes to submit involuntary discharge notices to the

Ombudsman program. In addition to sending notices through secure or regular mail, the 

State Ombudsman created a secure fax line that allows nursing homes to transfer notices 

electronically to a secure email inbox. Nursing home staff found the approach to be 

easier and less time consuming than earlier practices, and the electronic option was in 

closer compliance with record retention rules. Similarly, the Tennessee Ombudsman 

program established a secure email address for receiving discharge notices and likewise 

found that the approach improved the notification process. 

Given the number of questions from facility staff regarding the new federal regulation and 

state-level protocols, programs nationwide also needed to provide technical assistance to 

facility staff and direct them to relevant resources. To address this need, the North 

Dakota Ombudsman program revised their Questions and Answers document on 

admission, discharge, and transfer rights to reflect the new guidance. 

ABOUT NORC

NORC at the University of Chicago is an independent research organization headquartered in downtown Chicago with additional offices 

on the University of Chicago’s campus, the DC Metro area, Atlanta, Boston, and San Francisco. NORC also supports a nationwide field 

staff as well as international research operations. With clients throughout the world, NORC collaborates with government agencies, 

foundations, educational institutions, nonprofit organizations, and businesses to provide data and analysis that support informed 

decision-making in key areas, including health care, education, economics, crime, justice, and energy. NORC’s decades of leadership 

and experience in data collection, analysis, and dissemination—coupled with deep subject matter expertise—provide the foundation for 

effective solutions.

Resource

North Dakota’s Question 

and Answer Booklet: 

https://www.ndhealth.gov/hf

/PDF_files/Nursing%20Ho

me/Adm_Transfer_Dischar

ge_Q&As_12-2016.pdf