When Hawaii established the state’s first long-term care ombudsman program in 1979, residents of nursing homes, care homes, foster homes and assisted living facilities gained an independent advocate to help ensure their quality of care.

But a key problem from 43 years ago persists today: There is a stark lack of access to the federally mandated ombudsman on neighbor islands.

Hawaii’s island geography makes it difficult for staff from the Honolulu-based ombudsman program to build trust with long-term care residents on neighbor islands or proactively monitor facilities outside Oahu.

And despite guidance from the National Academy of Medicine that Hawaii ought to retain a minimum of six ombudsmen for its nearly 13,000 long-term care residents, the state for many years has had just one.

people who cannot leave the house due to an epidemic
State long-term care ombudsman John McDermott says residents of long-term care facilities outside Oahu don’t have the same access to his federally mandated service. Getty Images

When the state’s lone ombudsman couldn’t fly interisland during the worst of the coronavirus pandemic, and later in the Covid crisis when securing a rental car became an expensive, near-impossible feat, the need for ombudsmen stationed on the neighbor islands became painfully clear, advocates say.

“That office is grossly understaffed and it just doesn’t make sense,” said Audrey Suga Nakagawa, advocacy director for AARP of Hawaii, a nonprofit organization with about 140,000 members.

Now state lawmakers are considering a pair of bills, Senate Bill 2676 and House Bill 1824, that would create five new full-time ombudsman positions, giving the program a total of two ombudsmen dedicated to Oahu, one on Maui, one on Kauai and two on the Big Island in Kona and Hilo, as well as the statewide ombudsman who oversees the program.

Sen. Sharon Moriwaki, who sponsored one of the bills, said when lawmakers considered a similar bill last year it was tabled due to pandemic-related funding constraints.

“I don’t know why it’s been so overlooked historically over the years,” Moriwaki said. “It seems like an easy yes.”

The issue, according to McDermott, has been finding the funding to create new staff positions.

“State workers come with state pensions and benefits, and yes, I understand that nobody wants the size of state government to get bigger because all of us taxpayers are footing the bill for that,” he said. “But this is really an issue of fairness. The neighbor island folks pay the same state taxes as Honolulu does. But Honolulu has access to me, and the neighbor islands have access to me when I have the time to go there. It’s not the same. It’s not fair. So they really need to have their own ombudsman.”

In his budget plan for fiscal year 2023, Gov. David Ige would fund two additional positions for the state’s long-term care ombudsman program. Moriwaki said she is optimistic that the Legislature will pass legislation to fund all five new positions the program is seeking.

The House passed HB 1824, which now heads to the Senate. SB 2676 has been referred to Ways and Means for its final senate hearing.

‘It’s Just Kind Of Obscene’

When he joined Hawaii’s long-term care ombudsman program at the Executive Office on Aging in 1998, John McDermott led an office that consisted of himself and another ombudsman assigned to Oahu.

John McDermott during hearing on unlicensed care homes Capitol room 329.
John McDermott, Hawaii’s long-term care ombudsman, said he continues to be concerned by the program’s chronic staffing shortage. Cory Lum/Civil Beat/2018

In 2001, the office gained a full time volunteer coordinator and a clerical support staffer. But by 2015, the Oahu ombudsman and clerical support positions had been eliminated and the volunteer coordinator position was left unfilled.

Until Tuesday, when the office regained an Oahu-focused ombudsman position, McDermott had been the state’s lone ombudsman for seven years.

“When you go to a facility on the neighbor islands and they haven’t seen you in a year, you have to reestablish who you are, show your badge, explain how you’re there as their advocate,” said McDermott, who is 63. “It takes a little while to get people to open up and start talking to you because now you’re a stranger. And the facility knows they’re not going to see you for another year or six months because you have too many other places you have to go to.”

In the absence of sufficient staffing, the state ombudsman program has relied on more than 200 volunteers over the last decade, as well as part-time contracted specialists.

But McDermott said this help, while appreciated, doesn’t make up for the absence of full-time staff members based on the neighbor islands who could build trust and rapport with long-term care residents and facility operators over time.

“The neighbor islands have been waiting 43 years for their own ombudsmen, and that’s just kind of obscene when you think about it,” he said.

‘The Need Isn’t Going Away’

In a typical year McDermott said he vets more than a thousand confidential complaints from long-term facility residents or their family members.

One recent complainant alleged that a neighbor island facility continued to charge its residents for a la carte services, such as assistance with medication management or bathing, even though these services were halted during the peak of the pandemic when staff members were afraid to enter residents’ rooms, according to McDermott.

Dignity Senior Living at Oceanside Hawaii building.
Last year state officials found there was caregiver neglect at the Dignity Senior Living at Oceanside in Hauula, a problem that might have been resolved sooner if McDermott’s program had more funding for additional staff. Cory Lum/Civil Beat/2021

McDermott recently stepped in to resolve a problem concerning a patient who was discharged from an Oahu facility without his clothes and other belongings, which were accidentally thrown away by staff members.

He’s currently addressing a complaint alleging that a facility on a neighbor island had threatened to discharge a housing insecure resident to a bus stop when he couldn’t find another place to live.

Another case McDermott said he’s working on concerns an obese nursing home patient on Oahu who doesn’t fit in his bed. For months the facility failed to do anything about the fact that the patient can’t sleep comfortably in his too-small bed, McDermott said.

“I’m fighting for the kupuna that are voiceless because of their dementia, because of their Alzheimer’s, because they have no family or because they have family but they’ve moved to the mainland,” he said.

In 2020, people 65 and older made up 19% of Hawaii’s population. As the state’s elder population continues to grow, experts say Hawaii is not prepared to meet the rising kupuna health care needs.

“The need isn’t going away,” said Caroline Cadirao, director of the state Executive Office on Aging. “In fact, it will probably increase.”

The elderly population is expected to continue to grow at a much faster rate than the overall population until 2030, according to a December 2021 report by Hawaii Department of Business, Economic Development and Tourism. And by 2040, one in four elderly people in Hawaii will be 85 and older, outpacing other states.

“Here’s a state with the longest longevity of life and I feel that we revere our older adults as much as anywhere,” Cadirao said. “And we’ve done a great job at supporting them in home and community-based settings, but I feel that we need to do the same for those in institutional settings, too, because they are the most vulnerable.”

Civil Beat’s health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and Papa Ola Lokahi.

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