Advocates say there aren’t enough of them in Texas long-term care facilities

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LUFKIN — Tonya Jackson left an Angelina County nursing home on a recent December day, happy with the successful resolution she brokered between the staff and a resident.

The elderly woman faced eviction after communication broke down between her family and the facility. That’s when Jackson stepped in.

Jackson is the Deep East Texas managing local ombudsman for long-term care facilities. Each day she serves Texans living at these facilities as a state-assigned independent advocate.

“We do not enter a nursing facility to wreak havoc,” Jackson said. “We enter the nursing facility to assist and advocate for the residents who do not feel they have a voice. We are there to help mend the broken bridge.”

There are not enough people like Jackson in Texas, which has a dismal track record for long-term care. The state ranked 42nd for safety and quality, on a 2018 scorecard from AARP, the last time the survey was taken.

The lack of ombudsmen — which include both paid staff and volunteers — is a statewide issue, and is acute in Deep East Texas, which includes Angelina, Nacogdoches and Newton counties. Just five people, two paid staff and three volunteers, bounce between 48 long-term care facilities — 34 nursing facilities and 14 assisted living facilities.

“We would be lost in the long-term care community without them, but they definitely need more support across the board,” said Andrea Earl, the associate state director of advocacy and research for the AARP.

In early December, the Deep East Texas Council of Governments, a group made up of representatives from local governments, called for more volunteers to bolster this program.

Jackson prays the extra hands will better support her small team. She believes one volunteer for each facility would go a long way toward improving the lives of residents.

“Volunteers can usually catch things that we can’t, being that our time is so limited going to each of the facilities,” Jackson said.

At the same time, state officials hope the Legislature will step in to provide extra support when they reconvene in January.

Patty Ducayet, the state’s lead ombudsman, wants lawmakers to fund more full-time and part-time positions, regulate the use of Medicaid and create a portal to handle involuntary discharge, the eviction of residents.

Texas legislators have signaled they intend to prioritize dementia care and research this session. Earl hopes this means they’ll see the value in prioritizing the ombudsman program as well.

The program has faced an uphill battle in past sessions.

“This session, we have to continue to lay the groundwork to ensure that legislators over in the big pink building understand that this is a critical office to long-term care residents and families,” Earl said.

The role of an ombudsman

The state ombudsman works independently from the Health and Human Services Department, which oversees the state’s long-term care facilities. This independence provides ombudsmen the chance to work on behalf of residents without fearing retribution.

Texas utilizes full-time employed ombudsmen to investigate complaints related to the health, safety, welfare and rights of residents in care facilities and help resolve any issues. Their work is ideally supplemented by a large force of volunteers who do similar work but for only a few hours a week.

Jackson tries to see 15 to 20 people at each facility during her monthly visits. If she’s successful, she’ll meet with every resident at least once a year.

The job requires patience and empathy, Jackson said. In many places, ombudsmen are the only visitors residents get from the outside world and the conversations provide them a level of peace.

Her visits serve not only to connect with residents but also to establish a rapport with staff at each facility so she can more effectively address complaints.

Facilities without that rapport may see ombudsmen as people just trying to stir up problems, Earl said. Ombudsmen and facilities have clashed before. In 2023, the Texas Assisted Living Association worked with Rep. Travis Clardy, R-Nacogdoches on legislation that Earl said would have made the job of ombudsman harder. The legislation would have limited what files ombudsmen could review, even when it is requested by the patient, Earl said.

“Accessing those documents and looking at history, especially when we're talking about dementia patients and those facing severe medical issues, is a key part of what they do,” Earl said.

Carmen Tilton, the vice president of public policy for the Texas Assisted Living Association, said the organization supported House Bill 4220, which would have impacted ombudsman access to patient records. Their goal wasn’t to curb access, however, but to bring Texas regulation in line with federal regulations.

Prior to this, even volunteer ombudsmen – without consent from residents – could access any resident information. This meant they could access Social Security numbers, bank account information, doctors information, prescriptions, and more, Tilton said. The bill also sought changes to training to clarify the differences between facilities and to establish guidelines for what is an ombudsman’s job and what is that of law enforcement.

“It was perceived as an attack on the program, which was not our intent,” Tilton said.

Clardy dropped the bill before it went for a vote. Since then, the ombudsman office has worked with the Texas Assisted Living Association directly to institute many of the changes Tilton hoped to see within the organization's framework without requiring legislative intervention.

Making changes actually happen within the facility can be difficult, slow and may result in backsliding instead of progress, Ducayet said. An ombudsman may fix a problem for one resident only to be back in the same facility facing the same problem with another resident. This can be extremely frustrating and requires volunteers and staff to have patience.

When done right, the issues are resolved within the facility — between the administration, residents and their families — and don’t require state intervention. Jackson does a good job of this, said Lynne’ Nix, the business office manager for Shady Acres Health & Rehabilitation in Newton County.

Nix’s relationship with Jackson has been built on the belief that Jackson’s interventions help both the facility and the resident. Sometimes a resident isn’t comfortable speaking their mind and the situation deteriorates quickly. The ombudsman is the logical answer.

“They're the true advocates for the residents,” Nix said.

A shortage of ombudsman

In 2024, the state ombudsman program had a 25% turnover rate of paid staff, the highest it has ever been. Those who have stayed are overworked, Ducayet said. Ideally, Texas would have one staff member for every 2,000 licensed care facility beds. Right now, Texas has one person for every 2,514 beds, she said.

If the program was fully staffed, then paid personnel could focus their work on recruiting and supporting more volunteers, Ducayet said. An additional 22 full-time employees would further improve advocacy statewide.

Local volunteers, who are often people whose family members are in long-term care facilities, or are eyeing a facility for themselves, serve as the “boots on the ground,” Earl said.

They can accomplish a lot if they can focus on one or two facilities at a time, Ducayet said. But that’s not a reality for Texas right now. Since 2019, the number of active volunteers has decreased by more than 100 people, leaving only 300 people to serve as volunteers across the state.

The work, whether as a volunteer or a full-time staff member, takes its toll.

Residents, who are often elderly or ailing, die. The sudden loss of a person who you have been meeting with for months, or even years, can be extremely difficult, Ducayet said. After serving in the field for 18 years, she learned that any meeting with a person could be her last.

“Those are hard things,” Ducayet said. “It takes resilience and grit, like most hard things do.”

Fewer staff and volunteers means longer times between visits to care facilities. Having more eyes and ears on the ground helps address problems at a facility more quickly, Ducayet said. This could go a long way toward improving elderly care and preventing problems from escalating to the point where state intervention feels necessary.

What can be done

Ducayet has several goals this legislative session to improve the ombudsman program and care for residents of long-term care facilities overall.

First is increasing state funding for the ombudsman program by about $3 million. This would cover the cost of 22 additional full-time ombudsmen statewide, including a quality assurance officer and discharge rights officer at the state level.

She also wants to resolve noncompliance with state and federal discharge rules by nursing facilities. Involuntary discharge, like what Jackson’s client was facing in early December, is the No. 1 complaint received by the program. Ducayet believes creating an online portal for nursing homes to file discharge notices, hiring for a position that is over discharges statewide and making it increasing fines if a nursing home violates discharge laws will help.

Increasing staff at long-term care facilities should also be a priority, Ducayet said. She and the AARP are advocating for the state to require nursing homes to use 85% of Medicaid reimbursements for payroll.

This would put the money in the hands of caregivers, instead of corporations, Ducayet said.

A similar bill was proposed in 2023. The Texas Senate approved it, as did a House committee. But it never received a full vote by the state House. . Earl believes it can go all the way this year.

These goals may not necessarily resolve the major issues within the long-term care industry in Texas, but they would go a long way toward increasing accountability in the industry, Earl said.

The AARP shares many of Ducayet’s goals, and Earl believes the work completed during the 88th Legislative Session to educate lawmakers about the ombudsman program and how it’s funded could help them progress. She is optimistic, but also weary of what is gearing up to be a potentially complicated session.

While Ducayet is working at the state level to improve upon the program, Jackson has other goals – mainly: to find more local volunteers.

If she could find one volunteer for each of the 48 facilities in Deep East Texas, an 11 county region, then she could feel more confident that her program is truly meeting the needs of this vulnerable population.

Disclosure: AARP has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.