Long-Term Care Ombuds Program Funding Model Recommendations
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- 2020 Long Term Care Ombuds Program Funding Report 177Ced0E 54De 440E 97C9 6
Summary
A December 2020 report to the Legislature from the Washington State Department of Commerce, Community Services and Housing Division, giving Long-Term Care Ombuds Program funding model recommendations under SB 6168 Section 127(92). It quotes the budget proviso, which provided $10,000 for the department to recommend a sustainable funding model and convene stakeholder meetings. Its key findings state that the program resolves an average of 92% of complaints, operates on 58% of the recommended staffing level, and needs an additional $1 million in 2021 to meet IOM recommendations. The report recommends increasing state funding to meet IOM guidelines and extending the workgroup to study alternatives to a bed tax model. It also reviews the program's history and funding and closes with Appendix B, a state-by-state comparison table.
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Cite this document
“Long-Term Care Ombuds Program Funding Model Recommendations.”
Original at app.leg.wa.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/2020-long-term-care-ombuds-program-funding-report-177ced0e-54de-440e-97c9-6/
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Long-Term Care Ombuds
Program Funding Model
Recommendations
A report pursuant to SB 6168 Section 127(92)
December 2020
COMMUNITY SERVICES AND
HOUSING DIVISION REPORT TO THE LEGISLATURE
Lisa Brown, Director
2.3
Acknowledgments
Washington State Department of Commerce
Diane Klontz, assistant director, Community
Services and Housing Division
Alice Zillah, section manager, Research Services
Patricia Hunter, Ombuds, WA State Long-Term Care
Ombuds Program
Becca Duncan, research project coordinator,
Research Services
Washington State Long-Term Care Ombuds
Program
Patricia Hunter, Ombuds
Vicki Elting, Assistant State Long-Term Care
Ombuds
Washington State Department of Commerce
Nathan Peppin
Program Manager, WA State Long-Term Care
Ombuds Program
Nathan.Peppin@commerce.wa.gov
360.725.2862
COMMUNITY SERVICES AND HOUSING DIVISION
1011 Plum St. SE
P.O. Box 42525
Olympia, WA 98504-2525
www.commerce.wa.gov
For people with disabilities, this report is available
on request in other formats. To submit a request,
please call 360.725.4000 (TTY 360.586.0772)
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT
Table of Contents
Executive Summary ..................................................................................................................................... 2
Introduction ................................................................................................................................................. 4
A History of Long-Term Care Ombuds Programs in Washington State .......................................................... 6
Past and Current Funding of Washington LTC Ombuds Programs ................................................................. 8
Long-Term Care Ombuds Programs in other States .................................................................................... 13
Recommended Funding Model for the State LTC Ombuds Program ............................................................ 15
Recommendations to the Legislature ......................................................................................................... 18
Appendix A: Definitions.............................................................................................................................. 19
Appendix B: Full LTCOP by State Comparison Table ................................................................................... 20
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 1
Executive Summary
Overview
The State Long-Term Care Ombuds Program (LTC Ombuds Program) is a statewide, independent program that
advocates solely on behalf of the individuals who live in licensed LTC settings.
The LTC Ombuds advocates for residents of nursing homes, adult family homes, and assisted living facilities.
Its purpose is to protect and promote the resident rights guaranteed to residents under federal and state law
and regulations. Program staff and certified volunteers are trained to receive complaints and resolve problems
in situations involving quality of care, use of restraints, transfer and discharge, abuse and other aspects of
resident dignity and rights.
Authorizing Legislation
In 2020, the Washington State Legislature included a proviso in the supplemental Operating Budget, SB 6168
Section 127(92) as follows:
(92) $10,000 of the general fund—state appropriation for fiscal year 2021 is provided solely for the department to
make recommendations on a sustainable, transparent, and reactive funding model for the operation of the long-term
care ombuds program.
(a) The department must recommend a plan that:
(i) Serves all residents in long term care equally;
(ii) Is reactive to changes in service costs; and
(iii) Is reactive to changes in number of residents and types of facilities served.
(b) The department shall convene not more than three stakeholder meetings that includes representatives from the
department of social and health services, the department of commerce, the department of health, the office of
financial management, the office of the governor, the long-term care ombuds program, representatives of long term
care facilities, representatives for the area agencies on aging, and other stakeholders as appropriate. The
department must submit a report with recommendations to the governor and the appropriate fiscal and policy
committees of the legislature by December 1, 2020.
Key Findings
The LTC Ombuds Program is able to resolve an average of 92% of complaints received by the program.
This level of performance saves considerable costs as these complaints would otherwise be referred to more
expensive regulatory and legal systems or the courts. Because program Ombuds visit long-term care facilities
on a regular basis, they can spot problems before they escalate, saving the state time, money, and energy.
Washington State has successfully "rebalanced" the Medicaid long-term care population, due in no small part
to the help LTC Ombuds provide to move people requiring care out of acute-care settings and into the
community.
In this context, "rebalance" refers to the shifting of Medicaid long-term care residents from expensive nursing
homes into community settings. This effort, mandated by the State Legislature and accomplished by the
Department of Social and Health Services (DSHS) and the State Long-Term Care Ombuds Program, honored
the choices of many long-term care residents by helping them find care in community settings or in their own
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 2
homes. This reduced the amount of Medicaid residents in nursing homes and larger assisted living facilities.
This effort resulted in better quality of care, more independence, and cost savings for long-term care residents.
Washington's LTC Ombuds Program operates on 58% of the recommended staffing level.
Based on IOM guidelines, there are currently not enough LTC ombuds to visit and reach out to every long-term
care resident and facility as required by the Older Americans Act1. Based on Caseload Forecast projections, an
additional $1 million in funding is needed in 2021 to meet IOM recommendations. The expected increase in the
number of residents in long-term care will continue to increase future LTCO operational costs.
Recommendations to the Legislature
Increase state funding to fully meet IOM guidelines
Increased funding will allow the LTCO to adequately serve all residents in long-term care. The legislature
should also consider tying future increases to bed projections issued by the Caseload Forecast Council.
Extend and expand the working group to identify alternative funding mechanisms
The workgroup found that a bed tax model would not be recommended, to prevent placing additional costs on
long-term care residents. The workgroup recommends further study on an alternative to a bed tax model. In
addition, the workgroup recommends updating the IOM staffing formula, investigating the feasibility of
applying for Medicaid Administrative funds, and/or investigating equity issues among different facility types
and Medicaid and non-Medicaid residents. A new workgroup should be commissioned and should include a
representative from the Caseload Forecast Council, as well as a representative from Residential Care Services
at the Department of Social and Health Services (DSHS).
1 OLDER AMERICANS ACT OF 1965 [Public Law 89–73] [As Amended Through P.L. 116–131, Enacted March 25, 2020]
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 3
Introduction
Background
In 2020, the Washington State Legislature included a proviso in the supplemental Operating Budget requiring
Commerce to make recommendations on a sustainable, transparent, and reactive funding model for the
operation of the LTC Ombuds Program. The proviso is quoted directly in the Executive Summary.
The proviso2 directed Commerce to recommend a plan that:
Serves all residents in long-term care equally;
Is reactive to changes in service costs; and
Is reactive to changes in number of residents and types of facilities served.
Commerce's Community Services and Housing Division contracted with the agency's Research Services
Program to facilitate the stakeholder meetings and write the report.
Stakeholder Meetings
The proviso required Commerce to convene three stakeholder meetings, with members representing the
Department of Social and Health Services, the Department of Health, the Office of Financial Management, the
Office of the Governor, the Long-Term Care Ombuds Program, representatives of long-term care facilities,
representatives for the area agencies on aging, Commerce, and other stakeholders as appropriate.
The meetings were held on October 8, October 15 and November 13. Before, between, and after each of these
meetings, Commerce and LTC Ombuds Program staff worked together to prepare information for the
stakeholders, answer questions, and consolidate stakeholder ideas into a report with funding model
recommendations.
Each meeting was conducted virtually and was two hours long.
Meeting invitees, workgroup participants, and stakeholders who contributed to the content of the report
included the following:
Aaron Riley, Spokane Regional LTC Ombuds
Alice Zillah, Manager of Research Services at Commerce
Alyssa Odegaard, Leading Age Washington
Amber Leaders, Senior Policy Advisor for Aging and Behavioral Health, Office of the Governor
Amy Freeman, Contracted Attorney at WA State LTC Ombuds Program
Betsy Claridge, SE WA Regional LTC Ombuds
Betty Schwieterman, WA State Developmental Disabilities Ombuds
Cathy Knight, Head of King County Area Agency on Aging
Christie Spice, Deputy Assistant Secretary for Policy, HQSA, Department of Health
Dana Gargus, Kitsap Regional LTC Ombuds
Danielle Cruver, Office of Financial Management (OFM)
Deb Murphy, LeadingAge Washington (Non-Profit Provider Association)
2 SB 6168 Section 127(92)
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 4
John Ficker, Adult Family Council of Washington
Maria Langlais, King County Area Agency on Aging
Melanie Smith, Lobbyist for WA State LTC Ombuds Program
Nathan Peppin, State LTC Ombuds Program Manager, CSHD, Commerce
Patricia Hunter, WA State Long-Term Care Ombuds
Rebecca Duncan, Workgroup Meeting Facilitator, Research Project Coordinator at Commerce
Robin Corak, Multi Service Center CEO
Robin Dale, President and CEO of Washington Health Care Association
Ron Vivion, Council on Aging and Disability
Rosemary Biggins, State Unit on Aging Program Manager, DSHS
Stacey Smith, Washington Area Agencies on Aging, Kitsap
Vicki Elting, Assistant WA State Long-Term Care Ombuds
Walt Bowen, WA Senior Lobby President
At the first meeting, participants had an open discussion about the main concerns of funding the LTC
Program. At the second meeting, Commerce and the State Ombuds shared ideas for funding models,
answered the members' questions, and opened the floor for discussion on elements of the funding model and
recommendations to the legislature. At the third meeting, Commerce and the State Ombuds shared the draft
funding model plan and report with recommendations for the workgroup to review.
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 5
A History of Long-Term Care Ombuds Programs in
Washington State
Establishment
Pursuant to the Older Americans Act, enacted by Congress in 1965, the Washington State Legislature
established the Washington State Long-Term Care Ombuds Program (LTC Ombuds Program) in 1983 within
the Department of Social and Health Services (DSHS).3 Five years later, the legislature exercised its option
under federal law to remove the LTC Ombuds Program from DSHS and place it within a private nonprofit
organization pursuant to a contract with the state. Today, the LTC Ombuds Program is organizationally located
within the Multi-Service Center (MSC), a 501c3 organization that serves as a host agency for the Program
pursuant to a contract managed by Commerce's Community Services and Housing Division.
Advocacy for Vulnerable Adults
For the past 37 years, the LTC Ombuds Program has successfully resolved complaints on behalf thousands of
LTC residents. Complaints to the program pertain to a variety of areas that impact residents' lives, including
quality of care; autonomy and privacy; access to information and services; transfers and discharges; and
abuse, neglect, and exploitation. For the past several years, over 90% of complaints have been solved to the
satisfaction of residents through low-level, informal problem-solving — the hallmark of LTC Ombuds advocacy.
On a systemic level, the LTC Ombuds Program has worked to secure legislative victories on behalf of
residents, including legislation to bring parity to the systems for civil penalties applied to adult family homes
and assisted living facilities.
Objectives and Organization of the LTC Ombuds Program
The LTC Ombuds Program is charged with:4
Coordinating the activities of over 20 LTC ombuds throughout the state
Protecting the confidentiality of records
Establishing a statewide uniform reporting system to collect and analyze data relating to complaints and
conditions in facilities, and
Providing resources to empower individuals, families and the community to ensure the safety and dignity
of all residents in long-term care settings.
The State Ombuds also works to:
Receive and respond to complaints filed with the Ombuds office
Advocate before the legislature on the dignity and quality of life of all people receiving long-term care, and
Monitor the work of state agencies that manage facility licensing, inspections, complaint investigations,
and enforcements and their policy and regulatory development.
The LTC Ombuds advocates for a highly vulnerable and ever-growing population in Washington: adult residents
of long-term care facilities. Both the State Ombuds and local ombuds programs have worked for decades to
ensure these adults receive the care they need and to promptly address problems or complaints. By resolving
3 WASHINGTON LAWS, 1983 CHAPTER 290, "LONG--TERM CARE OMBUDSMAN PROGRAM ESTABLISHED"
https://leg.wa.gov/CodeReviser/documents/sessionlaw/1983c290.pdf?cite=1983%20c%20290%20%C2%A7%203
4 43.190 RCW
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 6
complaints early, the LTC Ombuds Program prevents complaints from becoming bigger problems or costly
lawsuits, resulting in substantial savings in taxpayer dollars. For instance, in 1999, DSHS estimated that it
would cost them about $2.5 million to address the complaints that were resolved that year by the Long-Term
Care Ombudsman Program5. Adjusted for inflation, that $2.5 million translates to $3,871,113 in 2020 dollars. In
2019, the total budget for the State LTCOP was $2,149,195. Even if the workload for LTC Ombuds has changed
since 1999, the DSHS analysis demonstrates that it is much more cost effective for LTC Ombuds to address
long-term care complaints than DSHS, resulting in significant savings.
In addition, the LTC Ombuds Program is essential to connecting to every local ombuds, and thus connecting to
all of the many and varied long-term care facilities across the state. There are 12 regional LTC Ombuds
entities, hosted by area agencies on aging (AAA's), social services non-profit agencies, and regional offices of
the State Ombuds program. The twelve regional LTC Ombuds organizations include:
Aging & Adult Care of Central WA
Blue Mountain Action Council
Olympic Area Agency on Aging
Area Agency on Aging & Disabilities of SW WA
SNAP - Eastern Washington Long-Term Care Ombudsman Program
Northwest Region Long-Term Care Ombudsman Program
King Long-Term Care Ombudsman Program
Kitsap County Area Agency on Aging
People For People
Lewis/Mason/Thurston Long-Term Care Ombudsman Program
Pierce County Comm Connections, Aging & Long-Term Care
Snohomish Long-Term Care Ombudsman Program6
5 Washington State LTCOP, "About Us: Washington State LTC Ombudsman Program", 2020
6 Washington State Long-Term Care Ombudsman Program, "Find an Ombuds", https://www.waombudsman.org/find-ombudsman/
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 7
Past and Current Funding of Washington LTC Ombuds
Programs
Historic Funding Challenges
Despite the long history of the LTC Care Ombuds Program, funding streams and methods have not been
consistent from year to year. Each regional LTC Ombuds Program supplements federal and state funds though
grant funding and other fundraising activities. In addition, national recommendations for how to fund a LTC
Ombuds Program have not been updated since the 1990's. A 1995 Institute of Medicine (IOM) study, the IOM
recommends a standard staffing ratio of one full-time equivalent paid staff working as an authorized,
designated ombuds per 2000 long-term care facility beds.7 The report recommended that this 1:2000 ratio be
used as a "base indicator of performance and a unit of effort to determine the amount of additional resources
needed."8
The landscape of long-term care in Washington has changed dramatically since publication of the 1995 IOM
report. Each year, more people are entering long-term care facilities than are leaving them. Additionally, in the
last five years, the addition of a new type of assisted living facility known as Enhanced Services Facilities and
the addition of skilled nursing home beds in Crisis Access Hospitals has significantly increased the number of
beds under the purview of the LTC Ombuds. Furthermore, Washington is unique in comparison to other states
due to an increased number of adult family homes, which have fewer licensed beds but are placed throughout
communities. This means the long-term care beds in Washington have both increased over time and spread
out geographically.
Funding Streams for LTC Ombuds Program
The LTC Ombuds Program is supported by multiple funding sources (Figure 3). These sources include federal
dollars allocated through the Older Americans Act (OAA) and state general fund appropriation allocated
through the Department of Social and Health Services (DSHS) and passed to the Department of Commerce
(Commerce) through an interagency agreement. Commerce distributes the federal funding and general state
funds, and temporary funding from certain bills or initiatives. The State LTC Ombuds Program also receives
time-limited grants and shares these funds with regional LTC Ombuds programs. Each regional program finds
other ways to supplement state-allocated funds, such as acquiring funds from local governments, applying for
grants, and fundraising.
7 Institute of Medicine (US) Committee to Evaluate the State Long-Term Care Ombudsman Programs, "Real People Real Problems: An
Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act" https://pubmed.ncbi.nlm.nih.gov/25101383/
8 Institute of Medicine (US) Committee to Evaluate the State Long-Term Care Ombudsman Programs, "Real People Real Problems: An
Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act" https://pubmed.ncbi.nlm.nih.gov/25101383/
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 8
Figure 1: Summary of LTC Ombuds Program Funding in 20199
Short-term funding for
Federal: Older Americans State: General State Funds
Education for LTC Facilities RE:
Act (OAA), passes through for Commerce and Grants
rights of incapacitated persons
DSHS and then Commerce interagency contract with (supplemental)
as specified in HB1402 2017-
($444,004, or 21%) DSHS ($1,464,841, or 68%)
2018 ($240,350, or 11%)
State LTCOP:
Only ~24% stays with State
Program (~ $515,807)
Total for 2019:
$2,149,195
Legal Counsel Services:
11%, ~ $236,411
Funds passing through State LTCOP to Local allocations, grants,
Local LTCOP's: and fundraising
65%, ~ $1,396,977
Local LTCOP Funds
Figure 1 illustrates the LTC Ombuds Program budget in 2019. The total funding amount for the LTC Ombuds
Program in 2019 was $2,149,195. This budget overview does not include funds from grants, which vary from
year to year and are typically short-term.
The majority (68%) of program funding is from state general fund appropriations. A portion of funding in 2019
originated from a bill requiring the LTC Ombuds provide education for LTC facilities regarding rights of
incapacitated persons as specified in HB1402, 2017-2018, but this funding was only allocated for five years.
Close to two-thirds (65% on average) of overall funding goes to local programs, with only 24% of the budget
directed to the LTC Ombuds Program Office. The remaining 11% funds legal counsel services, which are
contracted to two private attorneys.
Current Coverage
The current funding provided by the Legislature ($1,464,841 as of 2019) is inadequate to provide enough staff
as recommended by the Institute of Medicine.
The LTCOP serves 73,991 beds in long-term care facilities in fiscal year 2021.
Per IoM recommendations, at least 37 full-time staff should serve this number of beds to advocate for
residents, address complaints and visit facilities. However, there are only 21.19 FTE for regional ombuds
programs and four FTE for the state Ombuds office for 2021 due to limitations in funds. This includes
administrative or clerical staff.
9 Washington State Long-Term Care Ombuds Program Budget 2018-19
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 9
As a result, the regional and state LTC ombuds staff are stretched incredibly thin, with almost 12 fewer
staff members than recommended (only 57% of the recommended number) to advocate for the growing
population in long-term care facilities.
Figure 2: Actual vs. Recommended Washington LTC Ombuds FTE10
40 36.61 36.61 35.57 35.27 35.50 35.79
33.76 34.16 34.41 34.64
35
Number of Ombuds
30
25 28
25.55
20 26.7 22.76
15 19.31 18.81 18.48 19.72 19.62
18.18
10
5
0
FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Fiscal Years
All staff, state and local
Recommended total staff (based on 1 FTE/2000 beds)
Linear (All staff, state and local)
Figure 2 illustrates that the number of ombuds FTEs has not matched the recommended number at any point
in the last decade. A drop in staff numbers in 2012 was due to a decrease in funding, after a 2010 funding
proposal for the State LTC Ombuds Program was denied. However, the slow but steady increase in staff over
the last four years can be attributed to the hard work of the state and regional LTC Ombuds programs to find
other sources of funding, including increased funding award by the Legislature. Program costs have also
increased since 2010 due to inflation, health insurance costs and other direct and indirect costs.
Washington State is recognized across the nation as a state that has successfully "rebalanced" its Medicaid
long-term care population.11 Figure 3 shows the change in long-term care residents and facilities in
Washington since 2010. A sharp decline after 2013 in both the number of facilities and residents was due to
efforts to move people out of nursing homes and into community-based settings. The LTC Ombuds works as
part of the LTSS (Long-Term Care Services and Supports System) to inform all long-term care residents of their
long-term care choices, including but not limiting to moving out of comparatively expensive nursing home care
into less restrictive community-based care such as assisted living facilities or adult family homes. Through the
Community Option Program Entry System (COPES) Medicaid Waiver program and other state programs,
individuals in need of nursing home level of care can receive care in their own homes, allowing for more
independence.
10 WA State Annual Ombuds Report for Federal FY 2010 - 2019
11 Attached see the annual AARP and SCAN Foundation SCORE card ranking Washington State compared to other long-term care
services and supports systems (LTSS). https://www.longtermscorecard.org/
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 10
Figure 3: Long-Term Care Beds and Facilities in Washington12
74000 73224: At this time, the State LTC Ombuds Program began work 4300
73224
to rebalance Washington's Medicaid long-term care population.
73000 4200
4169
72000 71576 4100
4132 4132
70993
4000
71000 70540
71142
LTC Ombuds Program
3900
70000 69288
Bed Count
68818 3800
69000 3695 3676
3700
68317
68000 67516 3577 3575
3543 3600
67000
3548 3500
3660: While the number of residents in
66000 nursing homes decreased since 2013, the
3400
number of adult family homes (and
65000 residents there) has increased and 3300
continues to grow.
64000 3200
FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Fiscal Year
Bed Count Facility Count
The ombuds uses their knowledge about Medicaid, Medicare and residents rights to help residents advocate
for their choices in treatment, care and living environment. While this valuable work led to a reduction in the
number of people in nursing homes, the overall number of people in need of long-term care each year has
increased over time. While facility data is only available through state fiscal year 2019, the LTC Ombuds
estimates the total number of long-term care facilities in Washington is approximately 4,200 in as of January
2020.
Even as long-term care residents and facilities increase, the LTC Ombuds Program has effectively resolved
complaints with LTC facility providers. On average, 92% of complaints received by the program annually are
resolved by Ombuds,13 rather than referred to more expensive regulatory and legal systems or the courts.
State and regional LTC Ombuds staff and volunteers visit long-term care facilities on a regular basis. Ombuds
can spot problems before they escalate, saving the state time, money, and energy. However, the frequency of
visits to long-term care facilities varies greatly from community to community, and regular visits are becoming
more challenging for LTC Ombuds as the number of small facilities interspersed throughout communities
(such as adult family homes) continue to grow.
12 WA State Annual Ombuds Report for Federal FY 2010 - 2019
13 Washington State Long-Term Care Ombuds Program, "About Us: Washington State LTC Ombuds Program"
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 11
The Cost and Benefit of Volunteer LTC Ombuds
Figure 4: Number of volunteer LTC ombuds and volunteer hours per year over time
70000 500
444 450
60000 60049
400
Number of volunteers
53147 387
53873 377
368
Volunteer Hours
50000 358 347
48545 351 350
332 318 321
40000 300
38067 38519 39222 37093 250
32860 31713
30000 200
20000 150
100
10000
50
0 0
FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Fiscal Year
Volunteer Hours Number of volunteer ombuds
Volunteer LTC ombuds are essential to the functioning of the LTC Ombuds program in Washington. Volunteer
ombuds work with long-term care residents to inform them of their rights and hear their complaints. In 2019,
there were 368 volunteer Ombuds certified to address complaints in Washington, recording over 32,000
volunteer hours donated.
Some LTC ombuds programs have more volunteers than others, and the number of certified volunteer LTC
ombuds has changed over time (as shown above in Figure 4). According to the Independent Sector, a
membership coalition representing charitable organizations, the value of volunteer time in Washington in 2019
was $33.02 per hour.14 Therefore, in 2019, volunteers' contribution of 31,713 volunteer hours equated to
$1,047,163 of volunteer LTC ombuds work.
However, more volunteers working under the direction of an LTC ombuds requires more time for coordination
and oversight, and less time available to actively do ombuds work. Therefore, while volunteer LTC ombuds
save a significant amount of money, they also take noteworthy time (and money) to train and coordinate.
Furthermore, volunteerism has been changing over time in the United States. A study conducted by the
University of Maryland's School of Public Policy found that the national volunteer rate has been declining since
2005, and Washington saw a significant decrease in volunteer rates between 2004 and 2015.15 The LTC
Ombuds Program similarly saw a decrease in the number of volunteers after 2011, but it was followed by a
slight increase in volunteer numbers after 2018. This change in trends indicates that staff are working hard to
recruit and retain volunteer ombuds to address the needs in their regions and across the state. Given the
amount of time and energy it takes to recruit, train, and manage volunteer ombuds, the number of full-time LTC
ombuds needs to increase to expand volunteer LTC ombuds programs.
14 Independent Sector, "The Value of Volunteer Time / State and Historical Data" https://independentsector.org/resource/vovt_details/
15 University of Maryland, "Where Are America’s Volunteers? A Look at America’s Widespread Decline in Volunteering in Cities and
States" https://dogood.umd.edu/research-impact/publications/where-are-americas-volunteers
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 12
Unfortunately, the COVID-19 pandemic has only highlighted the challenges with volunteer programs and the
insufficiencies in the current funding streams. Many volunteer LTC ombuds have stopped working because of
health concerns, significantly reducing the LTC ombuds workforce in regions that rely on volunteers. In
addition, residents of long-term care facilities have been severely impacted by COVID-19 concerns, increasing
the amount of work for each paid LTC ombuds as they try to address the concerns of residents and advocate
for their rights and safety. In order to adequately serve the residents of long-term care facilities, the Ombuds
Program needs a more reliable funding plan that ensures there are enough full-time staff in each region to
serve residents equally and react to changes in service costs, resident numbers and types of facilities served.
Long-Term Care Ombuds Programs in other States
Every state is required to have a Long-Term Care Ombuds Program, but the structure of programs differ from
state to state.
In some states, long-term care ombuds programs are entirely managed by the state. In others, the state LTC
ombuds program is almost or entirely independent from the state. Funding sources vary, from state and
federal allocations, to independent fundraising, to placing fees on nursing homes based on bed count. To
examine these variations, we collected data on the LTC Ombuds Programs of twelve states, including
Washington. Figure 5 compares the number of long-term care facilities and beds in under the jurisdiction of
each state's LTC Ombuds Program. In addition, Figure 6 compares the coverage and budgets of each state's
LTC Ombuds Program. In this case, "coverage" means 1) the percentage of nursing homes the LTC Ombuds
visit quarterly, and 2) the ratio of recommended Ombuds staffing per the IOM to actual Ombuds staffing. For
the complete data set, please see Appendix B.
By comparing Washington with many other state LTC Ombuds Programs, we see that:
Washington has the third-most beds and facilities (and most of these facilities are adult family homes)
Despite the high number of residents and facilities, Washington has a mid-range budget (close to those of
Maryland, South Carolina and Wisconsin)
Washington has the fourth-lowest actual to recommended staff ratio (58%)
Washington has the third-lowest rate of quarterly nursing home visitation (30%), but this count does not
include the work done to visit the many adult family homes in Washington
Washington has significantly more adult family homes and assisted living facilities than all other states aside
from California and Wisconsin. However, the Washington LTC Ombuds budget is not significantly larger than
that of other programs. In addition, some states (such as Colorado and Maryland) have more paid staff than
recommended by the IOM, with actual to recommended staff proportions exceeding 100%. Many states with
higher actual to recommended staff proportions also boast high rates of nursing homes visited quarterly
(100% or over). Even California, with a paid staff ratio of 89%, has a 69% nursing home coverage rate. By
contrast, Washington has significantly less paid staff FTE than recommended, and the percentage of nursing
homes visited quarterly is relatively low (30%).
Among the states included in Figures 5 and 6, Washington has the fourth lowest actual to recommended staff
ratio (58%), but the largest number of LTC residents and facilities. In addition, the majority of these facilities
are adult family homes that are small and interspersed throughout communities, making it challenging for the
relatively low number of Ombuds to visit them regularly.
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 13
Figure 5: Comparing Long-Term Care Ombuds Program Facilities and Beds across
States - 20181617
9000 350000
8000
300000
7000
Number of Facilities
250000
Number of Beds
6000
5000 200000
4000 3575
150000
3000
70993 100000
2000
50000
1000
0 0
LTCOP Programs by State
# of Facilities Total Per State # of Beds Total Per State
Figure 6: Comparing Long-Term Care Ombuds Program Coverage across States -
20181819
200% $14
Millions
State LTCOP Total Budget
% of Coverage (staff and visits)
180% $12
160%
140% $10
120% $8
100%
80% 58% $6
60% $4
40% 30% $2.30
20% $2
0% $0
LTCOP by State
% of Nursing Homes visited Quarterly Proportion of Actual Staff to Recommended Staff
Total Budget Reported
16 National Ombuds Resource Center, Administration on Community Living, Administration on Aging
17 A full version of this table with additional state data can be found in Appendix B
18 National Ombuds Resource Center, Administration on Community Living, Administration on Aging
19 Appendix B contains a full table presenting all of this data, including budget data for each LTCOP
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 14
Under current limited resources, the Washington LTC Ombuds Program prioritizes responding to residents and
facilities with complaints and issues, to ensure the residents most in need of advocacy and assistance are
supported. Ninety-two percent of complaints received annually by the LTC Ombuds Program are resolved by
Ombuds. Even with limited resources and inadequate staffing, the State LTC Ombuds Program is making sure
that allegations of abuse and neglect are addressed promptly. Given the steady increase in need for long-term
care facilities and beds, the program's ability to maintain this level of responsiveness without a funding
increase is in doubt.
Recommended Funding Model for the State LTC
Ombuds Program
Funding Model Idea (Summarized) Stakeholder Response
Bed Tax or Fee System: for each designated Stakeholders did not support this model due to concern that the cost of
Long-Term Care bed in Washington, charge the bed tax or fee would be passed on to the LTC residents.
the responsible facility a flat tax or fee.
Revenue would go to the State LTCOP.
IOM Model: Total funding must support one Stakeholders supported this model, but were curious how the model
Ombuds for every 2000 long-term care could be updated (as the IOM recommendations come from a 1995
beds. study).
IOM and CFC Model: Total funding must Stakeholders supported this model, especially since it considers future
support one Ombuds for every 2000 long- growth of the long-term care population in Washington and is updated
term care beds, using future bed counts as from the 1995 IOM study. Stakeholders were interested in how this
projected by the Caseload Forecast model could be further fine-tuned to capture volunteer work and region-
Council. to-region variations in costs and workload.
Based on an historical review of the LTC Ombuds Program's funding, current funding needs, and the
workgroup discussions, the group recommends a funding model that relies on the IOM recommendation for
one FTE per 2000 beds. The exact number of FTEs would fluctuate from year to year based on long-term care
bed projections from the Caseload Forecast Council (CFC).
This simplified version of the model is as follows:
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐹𝑢𝑡𝑢𝑟𝑒 𝐵𝑒𝑑𝑠
( ) ∗ 𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑠𝑎𝑙𝑎𝑟𝑦, 𝑏𝑒𝑛𝑒𝑓𝑖𝑡𝑠, 𝑜𝑣𝑒𝑟ℎ𝑒𝑎𝑑 & 𝑙𝑒𝑔𝑎𝑙 𝑐𝑜𝑠𝑡𝑠 = 𝐹𝑢𝑙𝑙 𝐹𝑢𝑛𝑑𝑖𝑛𝑔 𝑓𝑜𝑟 𝐿𝑇𝐶𝑂𝑃
2,000 𝑏𝑒𝑑𝑠
Dividing the number of beds by 2,000 provides us with the number of FTE recommended by the IOM. Using the
CFC's bed projections provides the number of FTEs needed in the future to respond to increases and
decreases in long-term care residents.
Therefore, simplified further, the model is as follows:
𝐹𝑇𝐸 𝑁𝑒𝑒𝑑 ∗ 𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑠𝑎𝑙𝑎𝑟𝑦, 𝑏𝑒𝑛𝑒𝑓𝑖𝑡𝑠, 𝑜𝑣𝑒𝑟ℎ𝑒𝑎𝑑 & 𝑙𝑒𝑔𝑎𝑙 𝑐𝑜𝑠𝑡𝑠 = 𝐹𝑢𝑙𝑙 𝐹𝑢𝑛𝑑𝑖𝑛𝑔 𝑓𝑜𝑟 𝐿𝑇𝐶𝑂𝑃
The following describes how two key factors will be determined: the number of future beds, and the average
salary, benefits and overhead per full time staff member.
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 15
Projecting Future Long-Term Care Beds
Washington already has an agency that projects the number of long-term care beds to inform the state biennial
and supplemental budget: the Caseload Forecast Council (CFC). The CFC currently tracks past and current
needs for long-term care, including:
Home and Community Services (individuals in managed care, residential services and in-home services)
Nursing Homes (Medicaid eligible clients in state licensed nursing facilities)
The CFC also forecasts several years into the future each February as part of the state budget process, and
produces monthly monitoring reports comparing the budget forecast to the current forecast based on the
most recent statistics.20 The most recent projections published by the CFC (shown below) illustrate that the
sum of projected beds for both nursing homes (64,885) and home and community services (9,393) in 2022 will
total 74,277 beds. Basing LTCOP full-time staffing requirements on the total of 74,277 will allow for enough
staff to address not only current residents, but to assist and prepare for future residents of long-term care
facilities.
Figure 7: Forecast Beds for Home and Figure 8: CFC Forecast Beds for Nursing
Community Services21 Homes22
The workgroup finds that, given the historical reliability of the CFC projections, as well as the consistency with
use in the state budgets, using the CFC to build a funding model for the State LTC Ombuds Program is
recommended.
Calculating Salary, Benefits and Overhead
To calculate the funding model, the workgroup examined the total expenses of the LTC Ombuds Program in
federal fiscal year 2019, including costs for regional staff, state staff and legal counsel. According to the 2018-
2019 Ombuds Reporting Tool, the program was staffed by 25.55 FTEs in 2019. The funding sources include
federal funds under the Older American’s Act, state general fund appropriations, federal or state grant awards,
and local funding sources such as county awards, private or corporate grants/donations, Title IIIB, and Senior
Citizens Service Act (SCSA) funds to Area Agencies on Aging.
The total expenses for the LTC Ombuds Program in 2019 ($2,149,195) divided by 25.55 FTE results in an
average of $84,282 per full-time LTC ombuds. The costs per ombuds also include advertising, education,
20 Washington State Caseload Forecast Council, "Home", https://www.cfc.wa.gov/default.htm
21 Caseload Forecast Council: June 17, 2020
22 Caseload Forecast Council: June 17, 2020
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 16
conference and meeting costs, consultant costs, and other administrative costs essential to the functioning of
the State and regional ombuds programs. The salary average also includes the costs of approximately
$126,000 per year for legal counsel services, contracted to two private attorneys.
Sample Funding Model for 2021
Applying the funding model elements discussed above, the funding equation is as follows:
74,277 𝑏𝑒𝑑𝑠
𝐹𝑢𝑛𝑑𝑖𝑛𝑔 𝐿𝑇𝐶𝑂𝑃 = ( ) ∗ $84,282 = (37.1 𝐹𝑇𝐸) ∗ $84,282 = $3,130,107
2,000 𝑏𝑒𝑑𝑠
This equation provides the approximate amount needed to fund and staff long-term care in 2021. This model
does not consider differences in staffing and capital needs from region to region, but instead attempts to
demonstrate the costs needed to fully staff the program so that long-term care residents can be adequately
served. The value of volunteer LTC ombuds is also not captured in this model. Volunteers are discussed in
more detail in the following section.
Given the State LTC Ombuds Program 2019 annual budget of $2,149,195, and the total recommended funding
amount of $3,103,107, we can see the State LTC Ombuds Program is approximately $1 million underfunded.
The Recommended Plan to Fund LTC Ombuds Programs
The workgroup recommends that the Washington State Legislature increase the appropriation to the LTC
Ombuds Program to help reduce the $1 million gap in funding. The work done by the LTC Ombuds Program is
essential, and increased allocations would allow the program to fulfill its mandate to advocate for, protect, and
promote the rights of residents of nursing homes, adult family homes, and assisted living facilities. To
supplement these allocations, the State Ombuds would continue to pursue private and federal grants.
In addition, if the LTC Ombuds staffing level is increased the State Ombuds would work with regional programs
to determine whether or not it is cost effective to apply for Medicaid Administrative funding to supplement
regional programs.23 At this time, both state and regional Ombuds do not have the amount of staff available to
make Medicaid claiming cost-effective. The administrative work of applying for Medicaid funding takes a
significant amount of time, and the Department of Social and Health Services (DSHS) suggests that the time
and energy spent applying for this funding with the limited staff available would be greater than the amount of
funding received for many regions. However, if LTC ombuds staffing increased, there may be enough staff to
apply for Medicaid funding and continue providing ombuds services to LTC residents in the community.
It is worth noting that the IOM study which recommends one full time paid ombuds per 2,000 beds does not
account for the work of volunteer LTC ombuds or the staff time required to provide oversight, training and
management of these volunteers. In Washington, volunteer LTC ombuds contribute thousands of volunteer
hours working with residents of long-term care facilities each year. While some regional LTC ombuds
programs have more volunteers than others, and the number of certified volunteer LTC ombuds has changed
over time (as shown in Figure 5 on page 11), volunteers continue to be an essential part of the LTC Ombuds
Program. Furthermore, as discussed on page 11, volunteers save a considerable amount of money for the
state and regional LTC Ombuds Programs. Volunteers are an excellent return on investment; funding one full-
time LTC ombuds allows for the impactful work of dozens of volunteer ombuds.
23 *LTC Ombuds claiming activities cannot be duplicative of survey and certification functions or Medicaid waiver required assurances.
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 17
Determining how to account for volunteers when funding long-term care ombuds programs in Washington
requires further study. However, the workgroup strongly recommends increasing funds for full-time LTC
ombuds to expand volunteer LTC ombuds programs, ensuring that all residents of long-term care homes
receive the care and advocacy they need.
Funding Methods Not Recommended
A review of other states' long-term care programs found that some levy a "bed tax" or "bed fee," in which an
additional amount is charged to long-term care facilities per resident or per bed. While this is a reliable funding
method, the workgroup concluded that they would not recommend a bed tax as part of a funding model, due to
the impact on long-term care residents.
The proviso instructs Commerce to recommend a plan that serves all residents in long-term care equally, is
reactive to changes in service costs, and is reactive to changes in number of residents and types of facilities
served. After discussion, the workgroup determined that fees imposed upon facilities would likely be passed
on to the long-term care residents. A bed tax would disproportionately impact low-income residents and their
families, meaning that it would not serve all residents in long-term care equally. In addition, while a bed tax
may be a more reliable source of funds than seeking appropriations from the legislature each year, imposing a
bed tax on individuals in long-term care is in conflict with the mission of the LTC Ombuds Program to advocate
for improvements in the long-term care system.
Recommendations to the Legislature
1. Increase state funding to fully meet IOM guidelines
Increased funding will allow the LTCO to adequately serve all residents in long-term care. The legislature
should also consider tying future increases to bed projections issued by the Caseload Forecast Council.
This funding increase follows the Institute of Medicine (IOM) recommended formula: one full-time
equivalent paid ombuds for every 2,000 licensed long-term care beds.
2. Extend and expand the working group to identify alternative funding mechanisms
A new workgroup should be commissioned and should include a representative from the Caseload
Forecast Council as well as a representative of Residential Care Services at the Department of Social and
Health Services (DSHS) who specializes in long-term care facility licensing and enforcement. This
workgroup should focus on:
Finding an alternative to a bed tax model that does not place additional costs on long-term care
residents;
Refining and updating the IOM recommended staffing formula to reflect the variety in needs from
region to region. (The updated model should address proportions of complaints, different travel
requirements based on regional geography, different sizes of facilities, and the impact of volunteer LTC
ombuds);
Investigating the feasibility of applying for Medicaid Administrative funds to supplement funding for
regional LTC Ombuds Programs; and
Investigating equity issues among different facility types and Medicaid and non-Medicaid residents.
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 18
Appendix A: Definitions
Long-term care - A range of services and supports necessary to meet health or personal care needs over an
extended period of time. Most long-term care is not medical care, but rather assistance with the basic
personal tasks of everyday life, sometimes called Activities of Daily Living (ADLs) such as bathing,
dressing, eating, or transferring to or from a bed or chair. Other common long-term care services are
assistance with everyday tasks, including grocery shopping, managing money, taking medication, etc.24
Long-term care facilities - Are licensed by the Department of Health and Social services to provide ADL
assistance and every day help with tasks. This includes nursing homes, assisted living facilities, and adult
family homes.
Nursing home - any home, place or institution which operates or maintains facilities providing skilled
nursing services, rehabilitative therapies, convalescent or chronic care, or both, for three or more
unrelated patients who are unable properly to care for themselves. Nursing homes typically house
many residents in a large facility and provide skilled nursing services twenty-fours.25
Assisted living facility - any home or other setting serving seven or more residents which is advertised,
announced, or maintained for the express or implied purpose of providing housing and basic services,
and assuming general responsibility for the safety and well-being of the residents.26 Assisted living
facilities typically house many residents in a large facility. Assisted living facilities can and do provide
personal care services.
Adult family home - a residential home in which a person or persons provide personal care, special
care, room, and board to more than one but not more than six (or in some cases eight) adults who are
not related to the person or persons providing the services. Adult family homes are small facilities
embedded in communities which arose in the 1970s as alternatives to nursing homes.27
Long-Term Care Ombuds - Long-Term Care (LTC) Ombuds programs work to resolve problems related to
the health, safety, welfare, and rights of individuals who live in LTC facilities, such as nursing homes,
assisted living facilities, and other residential care communities. Ombuds programs promote policies and
consumer protections to improve long-term services and supports at the facility, local, state, and national
levels.28
WA State Long-Term Care Ombuds Program - the Ombuds Office is headed by a full-time State LTC
Ombuds who works with and advocates for LTC facility residents statewide. The State Ombuds designates
staff and hundreds of volunteers as representatives to directly serve residents.
24 Long Term Care.gov, "What is Long-Term Care?" https://longtermcare.acl.gov/the-basics/what-is-long-term-care.html
25 RCW 74.42.010 https://app.leg.wa.gov/rcw/default.aspx?cite=74.42&full=true#74.42.010
26 DSHS, " Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition"
https://aspe.hhs.gov/system/files/pdf/110636/15alcom-WA.pdf
27 HB 1277 Adult Family Home Quality Assurance Panel, "Adult Family Home Quality Assurance Panel Report: Recommendations to
the Governor and Legislature per ESHB 1277" https://www.waOmbuds.org/files/2012/03/quality-assurance-panel-report-2012.pdf
28 Administration for Community Living, "Long-Term Care Ombudsman Program" https://acl.gov/programs/Protecting-Rights-and-
Preventing-Abuse/Long-term-Care-Ombuds-Program
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 19
Appendix B: Full LTCOP by State Comparison Table29
% of
Nursin Staff
g FTE
# of Home Total Pai Endors Proportion
Nursi # of # of s Budge Certifie d ed by of Actual
ng Other Faciliti visited # of t d Staf IOM (1 Staff to
Hom Faciliti es quarte Beds Report Volunte f FTE/20 Recommen
State es es Total rly Total ed ers FTE 00) ded Staff
232 664 896 109.8% 44,74 $3.4 M 16 40.7 22 185%
Colorado
7 5
Marylan 230 239 469 100% 50,77 $3.1 M 85 34.9 25 140%
d 4
South 268 492 760 106.3% 43,12 $2.4 M 76 29.6 22 135%
Carolina 3 3
Mississi 212 200 412 98.1% 26,60 $1.2 M 0 15.5 13 119%
ppi 0
233 359 592 100.7% 38,25 $1.7 M 0 21.5 19 113%
Alabama
8
Californi 1,234 7237 8471 68.70% 3022 $12.5 M 511 134. 151 89%
a 95 51
Arkansa 239 191 430 100.8% 35,47 $1.1 M 227 15.7 18 88%
s 7 5
Wisconsi 384 4083 4467 18.20% 9108 $2.4 M 81 31 46 67%
n 3
Washing 230 3345 3575 29.6% 70,99 $2.3 M 377 20.7 36 58%
ton 3 6
Connecti 216 239 455 17.6% 36,04 $1.8 M 12 9 18 50%
cut 5
136 1896 2032 49.30% 4515 $1.5 M 139 11 23 48%
Oregon
6
Nebrask 223 285 508 78.9% 29,52 $325,00 55 6.75 15 45%
a 7 0
29 National Ombuds Resource Center, Administration on Community Living, Administration on Aging
LONG-TERM CARE OMBUDS PROGRAM FUNDING MODEL WORKGROUP REPORT 20
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