). 

SEPTEMBER 2019

Research Brief

Protecting Rights and Preventing Abuse: 

Systems Advocacy and Long-Term Care 

Ombudsman Program Organizational 

Placement

Authors: Kim Nguyen, PhD, and Emily White, MA 

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

This research brief explores the relationship between Long-Term Care Ombudsman programs’ organizational placements and their

ability to make improvements to the long-term care system. The brief begins by describing the program’s systems advocacy 

mandate and the legislative and regulatory prohibitions against organizational conflicts of interest (COI) that arise from program 

location. It then describes how organizational location intersects with program autonomy to pursue systems-level changes. Finally, 

the brief describes the role of organizational placement in programs’ ability to access resources and exercise their authority to 

effectively engage in systems advocacy activities. Findings suggest that, despite the organizational COI provisions outlined in the 

OAA and Final Rule, the extent to which Ombudsmen are able to engage in systems advocacy varies considerably between and 

within programs. Data used in this brief were collected as part of the Process Evaluation and Special Studies Related to the LongTerm Care Ombudsman Program conducted by NORC at the University of Chicago (NORC) on behalf of the Administration for 

Community Living (ACL).

BACKGROUND

In 1978, the Older Americans Act (OAA) established the 

Long-Term Care Ombudsman program (Ombudsman 

program or LTCOP) to protect and promote the health, 

safety, welfare, and rights of residents living in long-term 

care facilities. To advance this goal, the OAA charges the 

program with the responsibility to advocate for residents 

by identifying, investigating, and resolving individual 

complaints; making systemic improvements to the longterm care system; and providing outreach and education 

to residents and other stakeholders. These key 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 SLTCO) in 

coordination with a state or territorial unit on aging (SUA) 

in all 50 states, as well as the District of Columbia, Puerto 

Rico, and Guam. 

Under the OAA, the State Ombudsman is responsible for 

overseeing the statewide program while the SUA is 

responsible for the program’s organizational placement, 

and ensuring that the program has sufficient resources 

and protections to carry out mandated activities. 

DATA COLLECTION

As part of the Process Evaluation and Special Studies 

Related to the Long-Term Care Ombudsman Program, 

NORC collected qualitative and quantitative data from 

program staff and stakeholders in two phases. Interview 

data were collected from federal staff, national 

stakeholders, and State Ombudsmen in 2017. Survey 

data were collected from State Ombudsmen and a 

sample of local Ombudsmen and volunteers in 2018. 

For local data collection, a multistage stratified sampling 

approach was used. The sampling began with 

stratifying programs by the 10 ACL regions. To ensure 

that the diversity of programs was captured, a sample 

of 27 states was identified, and in these states, all local 

Ombudsman entities were included. Within each local 

Ombudsman entity, all local Ombudsmen were invited 

to participate, and half of volunteer Ombudsmen were 

randomly sampled and invited to participate. In 

centralized programs, staff who serve at the local level 

were included. More information about the study 

methods can be found in the Final Report that is 

available on ACL’s website (https://acl.gov

NORC at the University of Chicago Research Brief | 1 
Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

1The agency is standalone and provides advocacy, information, and referral services, including operation of the LTCOP. 

Exhibit 1: Office of the SLTCO Organizational 

Placement (N=53)

Exhibit 2: Local Ombudsman Entity Organizational 

Placement (NORS 2017; N=449) 

NORC at the University of Chicago Research Brief | 2 

States and territories are afforded broad flexibility in how to 

administer their Ombudsman programs and this 

administration is defined by both program structure and 

organizational placement. A program’s structure can be 

described as either centralized or decentralized and this 

program characteristic can interact in important ways with 

organizational placement. In a centralized structure, all 

program staff are employees of the agency housing the 

Office of the SLTCO (Office or State Office) and staff 

typically report to the State Ombudsman, regardless of their 

physical location (e.g. 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. One such local entity may be the area 

agency on aging (AAA), which are agencies that are 

responsible for providing information and services to older 

adults and their caregivers within their service area. There 

are 21 State Ombudsman programs that have a centralized 

structure, and 32 that have a decentralized structure. 

Organizational placement refers to the location of the Office 

of the SLTCO and local Ombudsman entities. At both the 

state and local levels, programs can be free-standing or 

they can be “hosted” by (or housed within) another agency 

or entity that is contracted by the SUA to administer the 

Ombudsman program. These include placement within

other state or local government agencies, in independent 

agencies within state government,

1 or within nonprofit 

organizations. According to the National Ombudsman 

Reporting System (NORS; the program’s administrative 

reporting system), most Offices were located within their

SUAs in federal fiscal year (FFY) 2017 (Exhibit 1). 

At the local level, nearly three quarters of local Ombudsman 

entities were housed within AAAs in FFY 2017 (Exhibit 2). A 

smaller number of host agencies include local government 

agencies, non-profit social services agencies, and legal 

services agencies. Six percent of local Ombudsman entities

are free-standing. It should be noted that within 

decentralized programs, there may be a mix of local host

entities. Ombudsman programs that are characterized by a 

centralized structure do not have local Ombudsman entities 

and are not reported here. These programs may have staff 

working in the Central Office or off-site throughout the state, 

in what is referred to as “Regional Offices of the State 

Ombudsman Program.” There are 74 of these regional 

offices. 
Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

SYSTEMS ADVOCACY AND 

ORGANIZATIONAL CONFLICT

OF INTEREST REQUIREMENTS 

UNDER THE OAA AND FINAL 

RULE

Within its systems advocacy mandate, the Ombudsman 

program “must address and attempt to rectify the 

broader or underlying causes of problems for residents 

of LTC facilities.”2

 Advocating for these systemic 

changes involves a broad and multifaceted set of 

activities. According to the OAA, systems advocacy 

efforts include, but are not limited to: 

■ representing resident interests before government

agencies and seeking administrative, legal, or other

remedies;

■ analyzing, commenting on, and recommending

system changes that benefit long-term care residents;

■ facilitating public comment on laws, regulations,

policies, and actions;

■ promoting the development of citizen organizations;

and

■ providing technical support for the development of

resident and family councils [Section 712(a)(3)].

In this role, the OAA envisions the Ombudsman program 

as an independent entity representing the interests of 

long-term care residents – not the interests of the state

or the aging network. This priority is critical because 

systems advocacy efforts may require the Office of the 

SLTCO to take public positions that are at odds with 

those of the SUA and/or other agencies that host it. As a 

result, independence is essential for the Ombudsman 

program to advocate in the interests of long-term care 

residents. Underscoring the OAA’s vision, the LongTerm Care Ombudsman Programs Final Rule (hereafter, 

Final Rule) describes the Office of the SLTCO as “a 

distinct entity, separately identifiable, and located within 

or connected to the State agency” [45 CFR §1324.11]. 

To ensure that programs have the independence to 

engage in mandated systems advocacy efforts, the OAA 

and Final Rule set forth requirements and clarifications 

concerning conflict of interest (COI) and organizational 

placement, as well as the scope of systems advocacy 

activities. Taken together, these requirements and 

2 Institute of Medicine. (1995). Real people real problems: An evaluation of the long-term care ombudsman programs of the Older 

Americans Act. J. Harris-Wheling, J. Feasley, C. Estes, (Ed.). Washington, DC: National Academy of Sciences. p.72.

clarifications aim to enable the program to freely and 

fully represent residents. With respect to organizational 

COI, the OAA stipulates that the SUA may not operate 

the Office of the SLTCO or carry out the program (either 

directly, or by contract with any public agency or 

nonprofit organization) if the program is located in an 

agency that also is responsible for licensing, certifying, 

or surveying long-term care services in the state [45 

CFR §712(a)(4)(B)]. The State agency must disclose 

any COI to the Assistant Secretary for Aging, and either 

remove the conflict or establish a plan to ensure the 

Ombudsman will be “unencumbered in fulfilling all of the 

functions” required of them. Remedying COI may involve 

relocating the State Office or establishing a 

memorandum of understanding (MOU) that clearly 

defines agencies’ roles and responsibilities. 

The Final Rule placed further emphasis on sheltering 

programs from perceived and actual organizational COI 

by identifying programs and functions carried out by host 

agencies (both for the State Office and local 

Ombudsman entities) that may affect the loyalty, 

autonomy, and perceptions of the Ombudsman program. 

These programs and functions include the following:

■ licensing or regulatory services for long-term care

facilities;

■ long-term care pre-admission screening or decisions

regarding eligibility, discharge, or admission for 

residents; 

■ care coordination or case management for residents

of long-term care facilities;

■ Adult Protective Services (APS);

■ guardianship or other fiduciary or surrogate decisionmaking services for long-term care residents;

■ an association or affiliate of long-term care facilities or

other residential facilities for older individuals or

individuals with disabilities;

■ provides long-term care to residents;

■ state long-term care facility rate setting; and

■ receives funds from long-term care facilities.

Should any of these programs, departments, or agencies 

reside in the same host agency as the Ombudsman 

program, 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 NORS, 

the program’s administrative reporting system. These 

NORC at the University of Chicago Research Brief | 3 
Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

requirements 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]. 

The Final Rule also offered an important clarification 

concerning the program’s system advocacy activities. It 

states that, “the provision of information, 

recommendations of changes of laws to legislators, and 

recommendations of changes of regulations and policies 

to government agencies by the Ombudsman or 

representatives of the Office do not constitute lobbying 

activities” [45 CFR §1324.13]. Because employees of 

government agencies are prohibited from lobbying in 

many states, this clarification ensures that Ombudsmen 

who are state employees can engage in a wide variety of 

systems advocacy activities. 

Despite this authority, as well as the organizational COI 

provisions outlined in the OAA and Final Rule, the extent 

to which Ombudsmen are able to engage in systems 

advocacy varies considerably between and within 

programs. According to 2017 NORS data, at the 

state/territory level, the estimated percentage of paid 

staff time spent on systems advocacy efforts such as 

monitoring/working on laws, regulations, government 

policies, and actions ranged between two percent and 

65% (with an average of 27%). At the local level, the 

estimated percentage of paid staff time spent on these 

systems advocacy activities ranged between zero 

percent to 25% (with an average of seven percent). The 

remainder of this brief explores the extent to which State

Ombudsmen report that their programs’ organizational 

placement facilitates or hinders systems advocacy 

activities. Particular attention is paid to the 

interrelationships between organizational placement, 

program independence, and access to resources.

ORGANIZATIONAL PLACEMENT 

AND SYSTEMS ADVOCACY

Program Independence 

Although the OAA and Final Rule set forth requirements 

concerning program independence and organizational 

COI to ensure that Ombudsmen can advocate freely on 

behalf of long-term care residents, our findings suggest 

there are persistent barriers to program autonomy, 

particularly for programs that are part of their state or 

territory’s SUA. When asked about program challenges

broadly, 22% of State Ombudsmen whose State Offices 

are housed in SUAs reported insufficient autonomy as a 

challenge faced by their statewide program. It is notable 

that no State Ombudsman whose Offices had other 

placements reported that program autonomy was 

insufficient (data not shown in exhibits). 

The relationship between a program’s organizational 

placement and its autonomy to engage specifically in 

systems advocacy is shown in Exhibit 3. The data show 

that State Ombudsmen whose Offices are housed within 

independent state agencies or nonprofits reported 

having the authority to carry out systems advocacy. 

These State Ombudsmen reported no restrictions with 

respect to four dimensions of autonomy under study. 

Findings on systems advocacy were mixed for the eight 

State Offices that are housed in state government (those 

not located in SUAs, independent state agencies, or 

non-profits). Whereas State Ombudsmen reported

Exhibit 3: Autonomy to Engage in Systems Advocacy of Statewide Ombudsman Program by State Office 

Organizational Placement

Statements about Autonomy of Statewide 

Ombudsman Program

State Office in 

SUA 

N=32

State Office in 

State 

Government

N=8

State Office in 

Independent 

State Agency

N=4

State Office in 

Nonprofit

N=8

My statewide program has been unable to fulfill some 

program duties due to legislative or regulatory restrictions. 23%* 25% 0% 0%

My statewide program has the autonomy to carry out 

systems advocacy work. 84% 100% 100% 100%

My statewide program is free to speak to the media. 69% 100% 100% 100%

My statewide program is able to represent the interests of 

residents to state agencies involved in long-term care 

without political interference.

75% 88% 100% 100%

*Missing=1

NORC at the University of Chicago Research Brief | 4 
Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

having full autonomy to carry out systems advocacy 

work and being able to speak freely to the media, a 

quarter of them also reported being unable to fulfill some 

program duties due to legislative or regulatory 

restrictions and being unable to represent the interests 

of residents without political interference.

By contrast, State Ombudsmen whose Offices are 

hosted by their SUAs were less likely to report freedom 

to speak to the media, publicly represent resident 

interests, and to carry out systems advocacy activities, 

compared to State Ombudsmen whose Offices have 

other organizational locations. Notably, State 

Ombudsman whose Offices are located within SUAs 

were the only group that reported not having the 

autonomy to carry out systems advocacy or the ability to 

freely speak to the media.

State Ombudsmen described a number of ways in which 

organizational placement can constrain programs from 

fulfilling mandated systems advocacy activities. With 

respect to the former, States that require state 

employees to register as lobbyists before they can speak 

to legislators or the media about long-term care issues 

or proposed legislation can place significant limitations 

on the number of program staff that are able to engage 

in these activities, despite the fact that the Final Rule 

clarified that these activities do not constitute lobbying. 

To a lesser extent, restrictions against lobbying also 

exist for programs that are housed in legal entities 

funded by Legal Services Corporation (LSC),

3 although 

this may affect local Ombudsman entities more than 

State Offices. 

Other restrictions on systems advocacy that are linked to 

organizational placement may be implied. For example, 

the SUA Director may strongly encourage the State 

Ombudsman to share their positions or statements prior 

to making them public. These requests can create 

tension if the positions or statements conflict with the 

SUA’s position on the same issues. In other cases, the 

SUA Director may require that a communications 

department or legislative director or liaison review the 

Ombudsman program’s public statements internally prior 

to their release. These requirements can influence how 

and when State Ombudsmen speak out on key issues, 

as well as which issues they choose to comment on 

altogether. 

To avoid conflicts that arise from being employed in a 

state agency, some State Ombudsmen turn to local 

Ombudsmen whose local Ombudsman entities are 

located in nonprofits or other independent agencies to 

carry out systems advocacy activities. As described 

earlier, organizational placement may differ at the state 

and local level. In a decentralized structure, for example, 

a State Ombudsman may work out of a state agency 

while their local Ombudsmen work out of a variety of 

host agencies, such as nonprofits. Under this 

arrangement, State Ombudsmen have reported that their 

local Ombudsmen are better positioned to comment on 

laws and policies, and encourage them to speak on 

behalf of residents when they cannot. For example, 

whereas State Ombudsmen employed by the state may 

not be able to actively pursue state general funds during 

the legislative process, Ombudsmen housed in a local 

entity may be better positioned to make the request.

By contrast, State Ombudsmen whose Offices are 

housed in nonprofits or an independent agency within 

state government reported that their organizational 

separation from the State host agency was an important 

factor supporting their ability to exercise their 

independence. They also reported that their 

organizational separation helped protect them from 

political or bureaucratic pressures that might restrict their 

programs’ efforts. 

Other impediments to program autonomy concern

organizational conflict of interest (COI) that result when 

the host agency offers multiple programs and services 

identified in the Final Rule or OAA as a conflict requiring 

a remedy or removal. Whereas State Offices that are 

housed in nonprofits are largely free from COI because 

the host agency does not engage in conflicting activities, 

placement within various state agencies can introduce 

challenges for a program’s independence if the Office is 

co-located with an agency that regulates or provides 

services to long-term care residents, among other 

conflicts. Although the Final Rule prohibits this type of 

co-location, our data were collected during a period 

when programs were not yet in full compliance with the 

regulation. Ombudsman programs were still working 

toward meeting the requirements of the Final Rule, 

including addressing provisions related to organizational 

COI and identifying new “homes” for their programs at 

both the state and local levels. 

3Established by Congress in 1974, Legal Services Corporation (LSC) is an independent nonprofit that provides financial support for civil 

legal aid to low-income Americans. LSC awards grants to legal aid organizations, some of which host local Ombudsman entities. 

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Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

State Ombudsmen also reported complications that can 

arise when State Offices are located in umbrella 

organizations that also host agencies that share legal 

counsel. For example, State Offices that are housed in 

SUAs (and to a lesser extent in a state government 

agency) may share legal counsel with agencies such as 

licensing and certification and APS, which can 

compromise the Ombudsman program’s ability to obtain 

impartial counsel when seeking to analyze, and publicly 

comment on legislation or policy affecting long-term care 

residents. Legal counsel that is shared between 

agencies may also have different philosophical 

approaches and priorities. For example, State 

Ombudsmen reported that when legal services are 

shared, assigned legal counsel may prioritize the host 

agency’s position over the Ombudsman program’s focus 

on resident rights. 

To comply with the Final Rule’s requirements, a few 

State Ombudsmen reported needing to relocate State 

Offices and local Ombudsman entities to remove COI. 

For example, one Ombudsman program relocated to 

another host agency because its SUA is responsible for 

setting nursing home rates and reimbursements and 

determining eligibility for providers. Similarly, local 

Ombudsman entities housed in AAAs that provide direct 

services and determine eligibility for settings in which the 

Ombudsman is involved, were relocated to other 

agencies to eliminate COI. 

Identifying, removing, or remedying organizational COI, 

however, is becoming more challenging as Ombudsman 

programs expand their advocacy services to the 

community at a time when states are redesigning their 

long-term care systems. The latter efforts often involve 

adding or consolidating responsibilities for home and 

community-based services to balance or optimize 

resources. When a single state agency oversees all 

long-term care resources, and the Ombudsman program 

covers long-term care facilities as well as community

and in-home settings, the expansion of duties presents 

increased opportunities for actual or perceived COI 

between the Ombudsman program’s systems advocacy 

work and host agency activities. Although State 

Ombudsmen reported addressing organizational COI 

was a positive development, they also reported that 

compliance with the Final Rule also introduced 

challenges in identifying a host agency that would be 

free of COI resulting from co-location. 

Program Resources

In addition to program autonomy, the availability of 

sufficient resources is a critical factor that affects the 

ability of Ombudsman programs to fulfill their systems 

advocacy responsibilities. However, three-quarters of 

State Ombudsmen reported having insufficient funding 

to carry out their programmatic mandates. With respect 

to pursuing systems advocacy, 48% of State 

Ombudsmen reported that facilitating public comments 

on proposed legislation, laws, regulations, policies, and 

actions are not fully carried out due to a lack of 

resources. 

Exhibit 4 shows the extent to which Ombudsman 

programs’ organizational placement supports access to 

various types of resources, and the data reveal 

important differences in resource availability across 

program placement categories. Overall, State 

Ombudsmen with Offices housed in SUAs were more 

likely to report having sufficient resources to meet their 

federal mandates than their counterparts housed in other 

agencies. These resources included legal counsel,

volunteer hours, communications methods to share 

information with consumers and stakeholders, as well as 

training and technical assistance. Although their 

numbers are relatively smaller, State Ombudsmen with 

Offices housed in nonprofits were most likely to report 

having sufficient numbers of paid staff and volunteers 

and administrative support, compared to State 

Ombudsmen with other Office locations. 

In interviews, State Ombudsmen whose Offices are 

hosted by SUAs often described the “built-in” resources 

they enjoyed as a result of their program’s placement. 

Because SUAs are responsible for administering a 

number of other programs for the aging and long-term 

care communities, they often have infrastructure that 

supports many of the Ombudsman program’s activities. 

That infrastructure includes dedicated departments to 

support information technology systems and human 

resources. It also includes data management and 

software systems, and office space.

NORC at the University of Chicago Research Brief | 6 
Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

Exhibit 4: Sufficiency of Program’s Resources to Meet Federal Mandates by State Office Organizational 

Placement

Resources that are Sufficient to Meet Federal 

Mandates

State Office in 

SUA

N=32

State Office in 

State 

Government

N=8

State Office in 

Independent 

Agency

N=4

State Office in 

Nonprofit

N=8

Fiscal resources 25% 25% 0% 25%

Legal counsel 66% 50% 50% 25%

# of paid staff 28% 13% 0% 50%

# of volunteers 19% 0% 0% 25%

# of volunteer hours 19% 0% 0% 13%

Data/information systems 66% 75% 75% 38%

Administrative support 47% 38% 25% 63%

Communication methods to share information with 

consumers and stakeholders 53% 38% 25% 50%

Training and technical assistance 59% 38% 50% 38%

Host agencies whose missions overlap with the LTCOP,

or agencies that have unique programmatic strengths 

may also support the Ombudsman program in important 

ways. For example, one State Office is located within a 

nonprofit that specializes in civil rights and discrimination 

issues among older adults and people with disabilities. 

The State Ombudsman reported that this placement is 

particularly helpful for systems advocacy because of the 

overlap in missions between the Ombudsman program 

and its host organization. Lead local Ombudsmen whose 

local Ombudsman entities are housed in legal services 

agencies also described their organizational placement 

as facilitating their ability to obtain legal support for 

systems advocacy efforts. 

In addition to the tangible resources (e.g. office space,

staff) that program location offers, organizational 

placement can also affect a program’s ability to access 

and leverage partnerships that facilitate the ability of the 

program to carry out its responsibilities. Many State 

Ombudsmen with Offices housed in SUAs described the 

benefits of being co-located with other relevant agencies 

in the aging network despite the potential COI that arise 

from residing in the same host agency. These benefits 

included greater opportunities for communication and 

increased awareness of current issues in long-term care. 

It should be noted that it was not clear whether these 

activities related specifically to systems advocacy 

activities.

By contrast, although State Ombudsmen with Offices 

housed outside SUAs reported a greater sense of 

autonomy, they also reported more challenges taking 

advantage of certain resources or partnerships to which 

State Ombudsmen within the SUA seem to have greater 

access or stronger connections. They also reported 

lower program visibility among agencies or organizations 

they might partner with in order to serve residents and 

carry out other program activities. Similarly, lead local 

Ombudsmen with local Ombudsman entities housed 

within AAAs and SUAs office often attributed facilitated 

communication with relevant partners or agencies 

located within the same host agency to their program’s 

placement. As described earlier, AAAs are responsible 

for delivering services to the long-term care community 

and their physical proximity to Ombudsmen may offer 

opportunities for more frequent communication. 

Similarly, lead local Ombudsmen who work out of SUAs 

and government agencies were less likely to report 

feeling isolated as a result of their organizational 

placement. 

Exhibit 5 shows the extent to which adequacy of 

resources facilitates Ombudsman programs’ ability to 

pursue systems advocacy activities. In general, State 

Ombudsmen with Offices that are part of SUAs or 

nonprofits were less likely to report being unable to carry 

out systems advocacy activities due to a lack of 

resources than their counterparts in state government 

and independent agencies. Notably, State Ombudsmen 

housed in independent state agencies seem to be most 

hampered in their ability to fully carry out these activities 

because of a lack of resources, particularly as it relates 

to resident and family council development and support. 

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Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

Exhibit 5: Systems Advocacy Activities Not Fully Carried Out due to a Lack of Resources by State Office 

Organizational Placement

Systems Advocacy Activities Not Fully Carried Out 

due to a Lack of Resources

State Office in 

SUA 

N=32

State Office in 

State 

Government

N=8

State Office in 

Independent 

Agency

N=4

State Office in 

Nonprofit

N=8

Resident and family council development and support 50% 75% 100% 63%

Analyzing and monitoring federal, state, and local law, 

regulations, and other government policies and actions 38% 50% 50% 25%

Research and policy analysis to inform systems 

advocacy work 47% 38% 50% 25%

Facilitating public comments on proposed legislation, 

laws, regulations, policies, and actions 44% 75% 75% 25%

Support from SUA Director 

Many State Ombudsmen discussed the importance of 

their SUA Director’s role in recognizing the program’s 

independence and advancing its mission for carrying out 

systems advocacy, regardless of organizational 

placement. Support can take the multiple forms, 

including providing the Ombudsman program with a 

“seat at the table,” facilitating partnerships, and 

supporting State Ombudsmen’s freedom to speak 

directly to decision makers about important issues 

related to long-term care without representing the SUA 

or state government. Several State Ombudsmen 

reported that the most important way their SUA supports 

their program is to allow the State Ombudsman to 

operate without interference or restriction. Helping the 

program make changes to program policies and state 

statutes to come into compliance with the Final Rule was 

also reported as a major form of support. Additionally, 

having a SUA Director who is knowledgeable about the 

Ombudsman program and long-term care, as well as 

someone who is communicative and generally 

supportive of the 

program’s purpose and mission were reported as major 

strengths. 

One State Ombudsman whose program is part of the 

SUA only understood the importance of the SUA 

Director’s support – beyond organizational location – 

when the SUA Director’s position became vacant. The 

previous SUA Director recognized the value and 

independence of the Ombudsman program and played a 

critical role in supporting the program’s autonomy and 

ensuring relevant stakeholders understood that the 

program and SUA are separate entities. With the SUA 

Director’s departure, the State Ombudsman reported 

less frequent inclusion in management meetings where 

decisions are made that affect older adults. 

Regardless of organizational placement, State 

Ombudsmen across program location categories 

reported relatively high support from their SUA Directors 

(Exhibit 6). 

Exhibit 6: Support from SUA Director by State Office Organizational Placement

Overall, how would you describe the 

support your Office of the SLTCO 

receives from the SUA Director?

State Office in 

SUA

N=32

State Office in 

State Government

N=8

State Office in 

Independent 

Agency

N=4

State Office in 

Nonprofit

N=8

Fully supportive 50% 38% 50% 75%

Very supportive 28% 50% 0% 13%

Somewhat supportive 16% 13% 25% 0%

Not supportive 0% 0% 0% 0%

Indifferent 6% 0% 25% 13%

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Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

The especially high level of support from SUA Directors 

reported by State Ombudsmen whose Offices are 

located in nonprofits may result from their belief that 

SUA Directors in their states perceive their programs to 

have a higher degree of independence. In these states, 

the State Ombudsman programs are clearly separate 

and distinct entities from the SUA and state government.

While State Office organizational placement alone does 

not appear to affect whether or not State Ombudsmen 

reported feeling supported by their SUA, having that 

support appeared to be particularly valued by State 

Ombudsmen whose Offices are housed within SUAs. In 

interviews, State Ombudsmen within SUAs provided 

concrete examples of how the SUA Director supports 

them. These included sending letters to stakeholders 

emphasizing the independence of the LTCOP, referring 

complaints or issues to the Ombudsman program, and 

establishing connections between the State 

Ombudsman and key stakeholders (e.g., governor, 

legislators). One State Ombudsman found it particularly 

helpful to have the SUA communicate the importance of 

the Ombudsman program’s independence to the AAAs 

operating their local Ombudsman entities. 

DISCUSSION

Since its establishment, the Ombudsman program has 

been charged with making improvements to the longterm care system that will benefit the care and quality of 

life of long-term care facility residents. To support 

implementation of this broad mandate, the OAA and 

more recently, the Final Rule, included provisions to 

address organizational COI to ensure that Ombudsmen 

can freely engage in systems change. However, 

restrictions that are linked to organizational placement 

continues to affect the extent to which Ombudsman 

programs fulfill their systems advocacy mandate. 

Our findings highlight the continued importance of 

Ombudsman programs’ organizational placement for

carrying out systems advocacy activities. Programs with 

organizational placements that are consistent with the 

requirements of the OAA and Final Rule are more likely 

to have the autonomy to pursue systemic changes in 

long-term care without constraints, compared to 

programs that are part of their SUAs. Placement of a 

State Office in a state umbrella agency increases the 

likelihood that the agency also hosts other programs or 

carries out functions that affect long-term care residents. 

The Final Rule recognizes that this type of co-location 

introduces the potential for perceived or actual COI, 

thereby potentially impeding the Ombudsman program’s 

ability to freely engage in systems advocacy. Among 

State Ombudsmen whose Offices are part of their SUAs, 

between 16% and 31% (Exhibit 3) reported some type of 

restriction in carrying out mandated systems advocacy 

work. By contrast, all State Ombudsmen whose Offices

are housed within independent state agencies or 

nonprofits reported having the authority to undertake

systems advocacy efforts and reported no restrictions or 

political interference with respect to regulations, program 

autonomy, freedom to speak to the media, and 

representing resident interests. 

On the other hand, a program’s organizational 

placement also affects its ability to access much needed 

resources that can facilitate the program’s ability to carry 

out systems advocacy efforts. Our data showed that 

State Ombudsmen whose Offices are housed within 

SUAs were more likely to report benefitting from access 

to resources than their counterparts in other

organizations. This was particularly true concerning 

access to legal counsel, training and technical 

assistance, and communication methods to share 

information with consumers and stakeholders. The 

importance of these resources is not trivial, as each is 

crucial for carrying out systems advocacy. Adequate 

training and technical assistance support Ombudsmen’s 

understanding of resident needs and the resources and 

strategies available to address them. Legal counsel is

important for analyzing and commenting on legislation, 

regulations, and policies that may impact the lives of 

long-term care residents. Communicating information to 

consumers and stakeholders about issues in long-term 

care is a major component of systems advocacy. Having 

the methods to deliver that information is not only

beneficial, but necessary.

Taken as a whole, organizational placement presents 

the LTCOP’s systems advocacy mandate with a difficult 

tradeoff between program independence and access to 

resources. Whereas State Ombudsmen whose Offices 

are housed in SUAs reported greater access to 

resources to support Ombudsman program operations, 

they also reported less independence than those that 

are housed in independent state agencies or nonprofits 

that benefit from organizational and administrative 

separation from the SUA. This enhanced independence 

was reported to provide greater freedom among State 

Ombudsmen to take positions on important issues 

related to long-term care residents, even when those 

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Protecting Rights and Preventing Abuse: Systems Advocacy and Long-Term Care Ombudsman Program Organizational Placement 

positions conflict with those of elected, appointed, or 

career officials with direct or indirect authority over the 

Ombudsman program. Yet, without sufficient resources

– many of which are offered by the SUA or other state

host agency – State Ombudsmen in independent

agencies and nonprofits perceive limitations in the extent

to which they can carry out systems advocacy as fully as

they would like.

Beyond Ombudsman programs’ organizational

placement is the role of the SUA Director in advancing 

program mandates. State Ombudsmen described the 

importance of having the SUA Director’s support, 

regardless of where their programs are located. Chief 

among the ways the SUA Director can support the 

Ombudsman program is providing the program with a 

“seat at the table,” facilitating partnerships, and

supporting State Ombudsmen to operate their programs 

without restriction, including the freedom to speak 

directly to decision makers about important issues 

related to long-term care without representing the SUA 

or state government. 

Conclusion 

Our data show that the extent to which Ombudsman 

programs are able to fulfill their systems advocacy 

mandate continues to depend in part on their 

organizational placement, independence, and the 

availability of resources that is often linked to program 

location. The authority and resources that are tied to a 

program’s location represent an important tradeoff in 

programs’ efforts to fulfill their systems advocacy 

mandate. Whereas organizational placement in a 

nonprofit or independent state agency supports 

autonomy, location in an SUA or related government 

agency often facilitates access to resources and 

relationships with coordinating entities. At the same time, 

as the responsibilities of SUAs, AAAs, and the 

Ombudsman program expands, the potential for COI 

grows between the Ombudsman program and the state 

and local agencies that house them. Remedying COI, 

however, also then becomes increasingly challenging for 

programs to identify new homes that are free from COI 

resulting from co-location. 

Findings also show that the SUA Director’s support is 

valuable for advancing the Ombudsman program’s 

mission regardless of organizational placement. Overreliance on an individual SUA Director’s support, 

however, may introduce risk should the Director leave 

the position because support for the program may also 

be diminished or lost. Legislative and regulatory 

requirements with respect to organizational COI help 

ensure that support for the independence of the 

Ombudsman program will endure.

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NORC at the University of Chicago Research Brief | 10