At the height of the pandemic, long-term care facilities cut visits to their residents, older adults who were the most vulnerable to COVID-19. Connie Grahovac’s phone wouldn’t stop ringing.
“You’re getting a call from a resident that’s in tears or a husband that’s at the window watching his wife die,” Grahovac said.
Grahovac is a long-term care ombudsman for the state of Michigan, advocating for residents of licensed homes, including nursing homes, homes for the aged, and adult foster care homes.
For nearly 13 years, she’s helped residents of these long-term care facilities navigate problems stemming from loneliness, social isolation and staff shortages. She also investigates complaints of involuntary discharges, inadequate food, a lack of staff assistance, care needs and other quality of life concerns.
During the lockdown, she couldn’t enter buildings, so she talked to residents in video chats or through window panes as she stood outside a facility. She answered desperate calls late into the evening.
“They just wanted human contact,” she said.
A burdened workforce
Michigan has 23 paid long-term care ombudsmen like Grahovac and about a dozen volunteers assigned to 14 regions. Ombudsmen undergo at least 36 hours of training and mentoring before visiting long-term care homes. Their services are free and confidential, and the program receives a mix of state and federal funding.
Top complaints include involuntary discharge or eviction, staff failure to respond to requests for assistance and issues with hygiene or medication. The program has received concerns over residents losing weight, soiling themselves or struggling to get out of a shower from lack of help, said Salli Pung, who heads the ombudsman program statewide. With consent from a resident, an ombudsman finds ways to rectify these problems.
You’re getting a call from a resident that’s in tears or a husband that’s at the window watching his wife die.”
Connie Grahovac,
LONG-TERM CARE OMBUDSMAN
The nation’s growing older adult population is expected to increase the demand for long-term care – and for these advocates. Employment at nursing homes is 10.5% below pre-pandemic levels, compared to 3.3% at hospitals and 1.6% at doctor’s offices, a University of Michigan study found.
Michigan’s long-term care ombudsman program supports a new mandate aimed to boost staffing standards at nursing homes. Released in April, a federal nurse staffing regulation states that all nursing homes who receive funding through the Centers for Medicare & Medicaid Services must have enough nurses and aides to provide each resident at least 3 ½ hours of care daily, with other provisions phased in over time. Healthcare industry groups challenged the rule in a lawsuit filed in May. About 19% of nursing facilities meet the mandate’s requirements, according to KFF.
All 50 states and the District of Columbia have a long-term care ombudsman program, per the Administration for Community Living, a government entity that supports aging people and those with disabilities. In some states, program resources are limited. The rapid expansion of long-term care facilities has increased the workload of ombudsmen.
Nationally, state long-term care ombudsmen were responsible for serving more than 3 million residents of 76,000 long-term care facilities in 2022, according to a Government Accountability Office report released in May. About 70% of the more than 180,000 complaints were filed on behalf of nursing home residents.
Officials leading long-term care ombudsman programs in Arkansas, Connecticut, Montana, Ohio and Oregon said ombudsman work and resident needs have become increasingly complex. Officials from two states surveyed said ombudsmen are working with more residents with mental health and substance misuse challenges or those with cognitive impairment.
Michigan’s ombudsmen are stretched thin. The state has roughly 5,000 licensed long-term care facilities with 105,000 beds. Each ombudsman has an average caseload of more than 5,000 beds, Pung said.
There is no minimum staffing ratio required by the Older Americans Act, per the Government Accountability Office report. In 1995, the Institute of Medicine recommended a staffing ratio of one long-term care ombudsman for every 2,000 beds.
In fiscal year 2022, the national staffing ratio was one full-time ombudsman per 2,193 beds. Officials from the Administration for Community Living said staffing ratios should be determined by each state depending on their needs and resources.
Financial relief is on the way. Michigan lawmakers recently granted an additional $3 million to the state’s long-term care ombudsman program for the 2025 fiscal year. Pung said this amount doubles the program’s current funding. With the extra money, the program plans to hire more ombudsmen and launch a volunteer recruitment campaign, Pung said.
At the time of a resident’s admission, nursing homes are required to provide information about the long-term care ombudsman program. Similar requirements don’t exist for homes for the aged and adult foster care, Pung said. The plan is to boost outreach to these settings.
In 2023, the state’s ombudsmen completed 3,284 case investigations, according to the program’s annual report. That number represents a 3.4% drop over the previous year.
Pung cautions against a rosy interpretation of the decline in complaints. Some residents reported quality of life concerns to ombudsmen but did not provide consent for an investigation.
“A lot of times, residents don’t want to say something, because of their fear of retaliation after we come and help them,” Grahovac said.
For instance, Grahovac assisted a resident in filing a hygiene complaint with the state licensing department overseeing nursing homes. Afterward, the home got a citation for the situation. The resident felt the home retaliated against him because aides were removed from his hall, Grahovac recalled.
Preserving comfort and dignity
Grahovac is stationed in the Upper Peninsula, driving long distances across large swathes of rural land to visit buildings. The winters can be unforgiving. She’ll instruct volunteers to learn everything they can about long-term care residents to build a meaningful connection.
In college, Grahovac wanted to become a kindergarten teacher. Outside of class, she worked in hospice. Grahovac remembered going to an older woman’s house. She helped the woman sign a document to enter hospice care then spent the night sitting with the woman who showed pictures of her grandchildren. After Grahovac left, the woman died that same evening.
The next day, the woman’s daughter contacted her. “‘All my mom talked about was the girl that looked at pictures with her,’” Grahovac remembered the daughter telling her. That moment shifted her calling to long-term care.
Michelle Danou has been an ombudsman serving suburban Detroit for more than five years. She left a career in business for social work. Sometimes, care can seem too clinical.
“Residents don’t get a hug,” Danou said. “Staff won’t hold someone’s hand if they’re upset. There’s a loss of human touch.”
Danou answers questions about Medicare and Medicaid benefits and what services insurance will cover in long-term care. “It’s a very complicated system,” she said.
Under federal law, residents in nursing homes are guaranteed certain rights. A right to equal access to care, presentation of grievances without discrimination, a reasonable accommodation to care preferences.
“The home’s responsibility is to help support and take care of a resident for whatever the resident’s wishes are,” Danou said.
Grahovac and Danou visit long-term care homes with a checklist in hand, observing if residents are living in comfort and with dignity. “We’re the resident’s voice,” Danou said.
They’ve seen subpar dietary plans, a popular complaint. “I couldn’t even cut the piece of chicken with a fork,” Grahovac said.
The corporate nature of some nursing home companies often frustrates the ombudsmen.
One time, Grahovac aided an older resident in a nursing home who was cold. But it took research and prodding with a corporate representative to finally get an electric blanket wrapped around the resident.
“I think sometimes staff don’t think outside of the box because of fear of regulations,” Danou said.
The pandemic bruised the mental health of residents, with lasting effects.
During their trips, Grahovac and Danou have seen an uptick in depression and anxiety but medical services are lacking.
Residents in long-term care homes often turn to telehealth, yet some don’t feel comfortable talking to a therapist through a screen.
In the Detroit area, Danou said contracted mental health providers offer limited services to long-term care residents and long-term care homes lack mental health staff.
“If a resident is having a mental health crisis, that clinician may not be able to come back to the home for a period of time,” she said.
The ombudsmen console residents who feel alone and ignored and whose unmet needs of basic amenities fester away from public view.
“When an individual goes into long-term care, their world changes. Their world’s turned upside down,” Danou said. “Often they don’t trust anymore.”
Sometimes, Danou has been the only person who visits a resident. Knowing someone is that lonely or alone can be heartbreaking but all hope is not lost. “That’s the beauty of our job,” Danou said. “We can help support them.”
To find a local ombudsman, call 866-485-9393 or visit the program’s website. To learn more about the program’s volunteer application process, go here.
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