PART C--NUTRITION SERVICE
SUBPART 1--CONGREGATE NUTRITION SERVICES
PROGRAM AUTHORIZED
SECTION 331

The Assistant Secretary shall carry out a program for making grants to States under State plans approved under section 307 for the establishment and operation of nutrition projects...

(1) which, 5 or more days a week (except in a rural area where such frequency is not feasible (as defined by the Assistant Secretary by regulation) and a lesser frequency is approved by the State agency), provide at least one hot or other appropriate meal per day and any additional meals which the recipient of a grant or contract under this subpart may elect to provide;
(2) which shall be provided in congregate settings, including adult day care facilities and multigenerational meal sites; and
(3) which may include nutrition education services and other appropriate nutrition services for older individuals.

From Connecticut

• Provide at least one hot or other appropriate meal in a congregate setting at least once a day, five or more days per week.
• When necessary (in case of illness, injury, etc.) make home delivered meals available to congregate meal participants.
• Serve a minimum of 98% of all meals to eligible participants and their spouces.
• Develop procedures for responding to emergency situations for all congregate sites and provide ongoing training on emergency procedures to all site managers and other site staff.
• Make nutrition education available to mealsite particpants at a minimum of once each quarter.
• Nutrition education subjects shall be based on the needs of the participants. Nutrition information and visual educational materials shall be available to the participants on a continuing basis.
• Each congregate nutrition site shall be open for at least three hours per mealtime unless a waiver is received from the Area Agency on Aging.
• Each congregate nutrition site shall be neat, clean and have adequate lighting, ventilation, and temperature control.

From New York

• To the maximum extent possible, sites are open at least five days a week in recognition of the greater impact on the nutritional status of participants.
• All sites are open at least one hour before and after the meal to permit all participants to eat a leisurely meal, enjoy social contact, and take advantage of other services at the site.
• To the maximum extent possible there is space available for supportive, educational and/or recreational services and activities.

There has been a steady decline in both the number of congregate participants and meals served (2). It is important that service providers identify means by which their congregate meal services can be expanded and improved. Ask the Experts Topics: Addressing the Image of Older Americans Congregate Nutrition Programs, Increasing Participation at Older Americans Act Title III Funded Congregate Meal Sites, and Restaurant-based Congregate Nutrition Sites and Restaurant Voucher Programs offer guidance and suggestions, some of which are included below.

SUAs should have policies and procedures in place to help nutrition providers enhance their programs. The following are some examples to consider:

• Increase flexibility, provide food choices and culturally proficient services.
• Have programs at different times during the day, such as breakfast or dinner.
• Provide a variety of activities, transportation to sites, and linkages to other nutrition and social services.
• Expand outreach activities and improve marketing.
• Use a restaurant as an alternative site to provide ethnic meals or food choices.
• Provide vouchers for individuals to redeem at participating restaurants, cafeterias (hospital or school lunchroom), grocery stores, food courts, etc.

The National Policy and Resource Center on Nutrition and Aging conducted a survey of nutrition providers, the Nutrition 2030 Grassroots Survey. Providing outreach and improved marketing were the top-ranked items in the congregate section.

B. HOME DELIVERED NUTRITION SERVICES

As with congregate meals, home-delivered meals (HDM) (sometimes called meals on wheels) help increase the nutrient intake of older adults at nutrition risk. HDM participants tend to have more health problems than congregate participants. The HDM service is associated with decreased hospital stays and allows participants to remain in their homes. The OAA allows much flexibility in the type of HDMs provided to older adults. Such meals may be delivered hot, cold, frozen, dried, canned or as supplemental foods. In addition, breakfast, lunch or dinner, or a combination of 2 or 3 meals, may be provided 5 days per week, but can also be provided on weekends.

A case manager often plays an integral role in the cross-referral and coordination of service delivery of home and community-based care services (HCBC). Since older adults are being discharged earlier from hospitals and nursing homes, many require a care plan that includes HDMs and other nutrition services, ie, nutrition screening, assessment, education, and counseling. Many states enroll Medicaid beneficiaries in Health Maintenance Organizations, use Medicaid HCBC waivers, and create state-funded programs to provide necessary HCBC medical, social, and supportive services including HDMs and nutrition education and counseling services (4).

In contrast to congregate meals, the number of HDMs has been steadily increasing each year. In FY 1988 there were 94.7 million HDMs served compared to 130 million in FY 1998, a 27.2% increase (1). The demand for HDMs will continue to increase due to health care cost containment and rapid hospital discharge. States need to evaluate funding sources to maximize the availability of HDMs as well as expand and enhance their nutrition services in response to the diverse and burgeoning number of older Americans.

SUBPART 2--HOME DELIVERED NUTRITION SERVICES
PROGRAM AUTHORIZED
SECTION 336

The Assistant Secretary shall carry out a program for making grants to states under State plans approved under section 307 for the establishment and operation of nutrition projects for older individuals which, 5 or more days a week (except in a rural area where such frequency is not feasible (as defined by the Assistant Secretary by regulation) and a lesser frequency is approved by the State agency), provide at least one home delivered hot, cold, frozen, dried, canned, or supplemental foods (with a satisfactory storage life) meal per day and any additional meals which the recipient of a grant or contract under this subpart may elect to provide.

From Connecticut

• Provide a nutritious home delivered meal at least once a day, 5 days a week. Meals may be hot, cold, frozen, dried, or canned foods with a satisfactory storage life.
• With the consent of the older person, or his/her representative, bring to the attention of appropriate officials for follow up conditions or circumstances which place the older person or the household in imminent danger.
• Make arrangement for the availability of meals to older persons in weather related emergencies.

From Oklahoma

• The Home Delivered Meals may be hot, cold, frozen, dried or canned with a satisfactory storage life, and must conform to procurement standards.
• The Home Delivered Meals service may include the delivery of more than 1 meal for each day's consumption provided that proper storage and heating facilities are available in the recipient's home.
  

The Nutrition 2030 Grassroots Survey found that increasing and maintaining volunteers and performing needs assessments were the top-ranked issues in the HDM section. The difficult challenge of deciding who has priority as a potential meal recipient when resources are limited is indicated by the emphasis on needs assessment as the second ranked item. There were differences by funding source for increasing and maintaining volunteers with privately-funded respondents giving that a higher ranking than did public or public/private, indicating that volunteers play even more important roles in privately-funded organizations.

C. MEAL SERVICE OPTIONS

It is common to provide a combination of two or three meals including breakfast, lunch and/or dinner, to participants receiving HDMs. Multiple meal packages are typically delivered with the noon meal. Breakfast, a popular meal with older adults, contributes to their health and well being by increasing intakes of critical nutrient dense food groups associated with positive health outcomes: cereals and grains, complex carbohydrates, fruits, fiber, milk, and milk products (5). Written eligibility requirements can help determine a participant's need to receive one or more meals. A best practice is to conduct periodic reassessments to determine the continued need for HDMs and the number of meals per day. Congregate nutrition programs may also serve breakfast and/or dinner in addition to or instead of lunch. Such services reflect the needs of a particular community or group and may only be provided on a limited basis during the week or month (e.g., 1 day per week or month).

Many homebound participants have functional impairments that make it difficult for them to shop and prepare meals. A number of nutrition programs offer weekend meals to frail, homebound participants receiving home-delivered meals. Weekend meals help contribute to a nutritionally adequate diet for these individuals and provides respite for family and friends. Written eligibility requirements, as noted above, would assist in determining a participant's need to receive weekend meals. Congregate nutrition programs may also serve meals on weekends at specific sites, again reflecting the needs of a particular community or group.

Frozen meals are often used in areas where daily delivery is limited, for weekend meal services, or to enable home delivered meal programs to offer more menu choices. The participant's kitchen (having appropriate appliances to store and reheat meals) and functional ability (can handle and/or heat meals) must be carefully considered when providing frozen meals. Frozen meals may also be used at congregate sites in rural areas where participation is small and other food service options are not feasible. Such meals would be heated and served at the site.

Emergency meals are generally shelf-stable ready to eat food products. Meal packages are generally provided to participants determined to need such food products if the program is unable to deliver meals due to weather or other problems. A best practice is to instruct participants on when and how they should use their emergency meal packages or to provide written suggestions for preparing their own emergency food stores. Program emergency preparedness is covered in Chapter X.

From Massachusetts

All Nutrition Projects must offer all home delivered meals clients, at the time of assessment, a shelf stable emergency meal package, available for use during inclement weather or other emergency situations, when the Project is unable to deliver meals.

• The case manager may identify current clients who may require an emergency meals package.
• Congregate meals participants should be advised to keep an emergency foods shelf at home in case of inclement weather.
• The emergency meal package for home delivered meals participants shall be delivered to clients by November 1 of each year.
• The package should consist of two to three days of shelf stable foods and shall be replenished by the Nutrition Project.
• It is recommended that the emergency meal package contain one-third RDA; the package should, as much as possible, match the regular menu pattern.
• The no added salt policy is waived for these meals, however, low sodium items are encouraged.
• Persons requiring unsweetened foods must be provided with appropriate items.

D. NUTRITION SERVICES INCENTIVE PROGRAM AND COMMODITIES

Nutrition Services Incentive Program is the new name for the U.S. Department of Agriculture (USDA) cash allotment or commodity program. The OAA authorizes the USDA to provide state agencies with either a cash allotment or commodities to encourage the effective and efficient delivery of meals funded through Titles III and VI of the OAA. States have latitude regarding whether they offer one or both of these options to nutrition projects. Although very few area agencies or nutrition projects use the additional option to use commodities, this is part of the program. Most SUAs do not use the commodity option and only a cash allotment is available. About 98.5% of the USDA funding is distributed as cash; 11 states use commodities. Examples of commodities are frozen or chilled beef or poultry, cheese, pasta, rice, canned or frozen vegetables, flour, vegetable oil, and butter.

Nutrition projects equipped to handle commodities may find them more cost effective than cash in lieu of commodities. Furthermore, additional commodities are available for state or area agencies on aging that take at least 20% of their program benefits as commodities.

States need written policies and procedures for use of cash and commodities, as well as reporting the number of meals served. Accepting USDA assistance is a necessary component of maintaining solvency of the OANP.

SECTION 311 NUTRITION SERVICES INCENTIVE PROGRAM

(a) The purpose of this section is to provide incentives to encourage and reward effective performance by States and tribal organizations in the efficient delivery of nutritious meals to older individuals.
(b)(1) The Secretary of Agriculture shall allot and provide in the form of cash or commodities or a combination thereof (at the discretion of the State) to each State agency with a plan approved under this title for a fiscal year, and to each grantee with an application approved under the title VI for such fiscal year, an amount bearing the same ration to the total amount appropriated for such fiscal year under subsection (e) as the number of meals served in the State under such plan approved for the preceding fiscal year (or the number of meals served by the title VI grantee, under such application approved for the preceding fiscal year), bears to the total number of such meals served in all States by all title VI grantees under all such plans and applications approved for such preceding fiscal year.
(2) For purposes of paragraph (1), in the case of a grantee that has an application approved under title VI for a fiscal year but that did not receive assistance under this section for the preceding fiscal year, the number of meals served by the title VI grantee for the preceding fiscal year shall be deemed to equal the number of meals that the Assistant Secretary estimates will be served by the title VI grantee in the fiscal year for which the application was approved.;
(c)(1) Agriculture commodities and products purchased by the Secretary of Agriculture under section 32 of the Act of August 24, 1935 (7 U.S.C. 612c), shall be donated to a recipient of a grant or contract to be used for providing nutrition services in accordance with the provisions of this title.
(2) The Commodities Credit Corporation shall dispose of food commodities under section 416 of the Agricultural Act of 1949 (7 U.S.C.1431) by donating them to a recipient of a grant or contract to be used for providing nutrition services in accordance with the provisions of this title.
(3) Dairy products purchased by the Secretary of Agriculture under section 709 of the Food and Agriculture Act of 1965 (7 U.S.C. 1446a091) shall be used to meet the requirements of programs providing nutrition services in accordance with the provisions of this title.
(d)(1) In any case in which a State elects to receive cash payments, the Secretary of Agriculture shall make cash payments to such State in an amount equivalent in value to the donated foods which the State otherwise would have received if such State had retained its commodity distribution.
(2) When such payments are made, the State agency shall promptly and equitably disburse any cash it receives in lieu of commodities to recipients of grants or contracts. Such disbursements shall only be used by such recipients of grants or contracts to purchase United States agricultural commodities and other foods for their nutritional projects.
(3) Nothing in this subsection shall be construed to authorize the Secretary of Agriculture to require any State to elect to receive cash payments under this subsection.
(4) Among the commodities delivered under subsection (c), the Secretary of Agriculture shall give special emphasis to high protein foods. The Secretary of Agriculture, in consultation with the Assistant Secretary, is authorized to prescribe the terms and conditions respecting the donating of commodities under this subsection.'
(e) There are authorized to be appropriated to carry out this section (other than subsection (c)(1)) such sums as may be necessary for fiscal year 2001 and such sums as may be necessary for each of the 4 succeeding fiscal years.'
(f) In each fiscal year, the Secretary of Agriculture and the Secretary of Health and Human Services shall jointly disseminate to State agencies, area agencies on aging, and providers of nutrition services assisted under this title, information concerning-
(1) the existence of any Federal commodity processing program in which such State agencies, area agencies on aging, and providers may be eligible to participate; and
(2) the procedures to be followed to participate in the program.

NOTE: Because these SUA policies were collected prior to the 2000 reauthorization of the OAA, authorizing Nutrition Services Incentive Program (NSIP) SUAs are revising policies to accommodate NSIP changes.

From Colorado

• Nutrition providers shall accept and use all commodities, including bonus commodities, made available by the state agency and funded by the USDA.
• Nutrition projects shall store commodities as prescribed in the "Donated Food Standard Agreement".
• The nutrition project shall accept only the quantity and type of food stated on the invoice. If the quantity is less than shown on the invoice, the nutrition project shall note this on the invoice, and request the deliverer to initial.
• Nutrition projects shall report any irregularities in the commodity shipping invoices to Food Assistance.

• Area agencies shall promptly and equitably disburse all USDA cash in lieu of commodities payments to nutrition providers that are funded with OAA funds.
• The distribution of such funds to the nutrition service provider(s) shall be in proportion to the number of meals served by each provider.
• Area agencies shall ensure that payments received by nutrition providers are used solely for the purchase of United States agriculture commodities and other foods produced in the United States; or Meals furnished under contractual arrangements with food service management companies, caterers, restaurants, or institutions, provided that each meal contains United States produced commodities or foods at least equal in value to the per-meal cash payment which the nutrition service providers have received.

From Montana

• The nutrition provider shall ensure that adequate inventory records are maintained on commodities received. The inventory must show commodities received, used and on-hand.

From Massachussetts

• The provider shall receive, handle, store and utilize USDA commodities made available for Title III-C, in accordance with State Policy and Procedure for Distribution and Control of Commodity Foods. The provider agrees to comply with these regulations around the proper use, storage, loss or damage of commodities and recording/accounting procedures involved. The provider will be responsible to the Nutrition Project and the State Distributing Agency in the outlined areas of responsibility.
• The provider recognizes the following responsibilities to be its own:
• The provider will make use of available USDA commodity foods made available by the Nutrition Project. The provider shall submit monthly credit vouchers for commodity foods received. The provider must use a minimum of $0.13 per meal for commodities for the month.
• To confer with the Nutrition Program manager and nutritionist in the ordering of commodities in accordance with an accepted utilization rate and to work with the nutritionist in designing menus to incorporate the available commodities.
• The provider shall properly store and mark for easy identification all commodity foods.
  
• To sign for receipt of shipment of commodities and notify the Nutrition Project of such in writing.
  
• The commodities to be credited will be the total value of the commodities received. Credit will be made on the month that the commodities are received.
  

A number of nutrition projects may also participate in the USDA Commodity Supplemental Food Program (CSFP). This program works to improve the health of low-income pregnant and breastfeeding women, infants, children up to age six, and people at least 60 years of age, by supplementing their diets with nutritious USDA commodity foods. It provides food and administrative funds to States to supplement the diets of these groups.

OAA Aging Services Network Programs and Organizations

1. Administration on Aging. 1998 State Performance Reports. Available at: http://www.aoa.dhhs.gov/napis/98spr/tables/default.htm. Accessed September 7, 2001.

2. Mathematica Policy Research, Inc. Serving Elders at Risk, the Older Americans Act Nutrition Programs: National Evaluation of the Elderly Nutrition Program 1993-1995, Volume I: Title III Evaluation Findings. Washington, DC: US Department of Health and Human Services; 1996.

3. Wellman NS, Smith J, Alfonso M, Lloyd J. (1999) Report: The Nutrition 2030 Grassroots Survey. Florida International University, Miami, FL.

4. Weddle DO, Faneelli-Kuczmarski M. Position of the American Dietetic Association: Nutrition, aging, and the continuum of care. J Am Diet Assoc. 2000;100; 580-595.

5. Weddle DO, Gollub E, Stacey SS, Wellman NS (1998) Final Report: The Morning Meals on Wheels Program Pilot Program: The Benefits to Elderly Nutrition Program Participants and Nutrition Projects. Florida International University, Miami, FL.

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Updated: 01/28/03

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