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Administration on Aging
National Nutrition Advisory Council Meeting
September 12 and 13, 1995
Doubletree Hotel, Arlington, Virginia
Drafted by
Jean L. Lloyd, M.S., R.D.
Nutrition Officer
Administration on Aging

ISSUE: The issue facing the Administration on  Aging (AoA) is how does the AoA, the National Nutrition Advisory Council  (Council), and the aging network develop agreed-upon national program goals,  objectives, measures of performance, and on-going mechanisms to evaluate program  impact on individuals and the service system for the Elderly Nutrition Program (ENP) of the Older Americans Act (OAA).

BACKGROUND: The AoA as a part of the Federal  government is faced with a daunting challenge--decreasing Federal funds,  increasing service needs, the demand for greater flexibility at State, Tribal  and local levels, the need for increased accountability to Congress and the American taxpayer, the need to improve Federal, Tribe, State, and local decision-making and to improve management of programs at all levels of the  hierarchy.

Nutrition services as funded under Title III, Parts C-1 and C-2 and Title  VI of the OAA, known as the ENP, are essential services that assist older  individuals in remaining independent and at home in the community. Over the past  30 years, the AoA has been able to chronicle the services provided to millions of older persons each year through the ENP. For example, the AoA can document how many congregate and home-delivered meals are provided to older persons each year. However, the AoA has not routinely documented or demonstrated the impact of these services on the lives of older persons.

Government Performance and Results (GPRA):
The Government Performance and Results Act (GPRA) of 1993 is changing this program management practice and reflects government-wide changes in directing programs. GPRA provides the AoA with the impetus to begin to focus attention on how OAA  programs and funds actually produce results. GPRA establishes strategic planning and performance measurement as the basis for program planning, implementation,  management, and continued funding for all major Federal programs. For each Federal agency and program, GPRA emphasizes: Defining the national program, its national goals and objectives; determining national program results not program  processes; informing decision-makers; and connecting Federal resources to program results.

The purpose of GPRA is to: Reduce Federal waste and inefficiency; improve  Federal program efficiency and effectiveness; improve Federal accountability;  and improve policy-making.

GPRA requires that each Federal agency, including the AoA, submit to the Office of Management and Budget (OMB) and Congress the following items: A  National Strategic Plan with Performance Indicators by September, 1997; an  Annual Performance Plan with Targets by September, 1997 for Fiscal Year (FY), 1999; and an Annual Performance Report by March, 2000.

GPRA provides the basis for more accountable Federal government and  defines a common framework for establishing goals and objectives and whether these objectives have been met. Because GPRA is new, the process for implementing GPRA is changing and developing differently in each Federal agency.  In its proposed reauthorization bill, the Administration has chosen to use Performance Partnerships between the Federal government and State units on aging  to implement GPRA. In Performance Partnerships, the partners, Federal, State,  local governments, and service providers: Jointly design the program and measure  program results; work to accommodate different program strategies with different  State and local partners.

National Goals and Objectives: Legislative history indicates that the ENP  was authorized to address the dietary inadequacy and social isolation of older individuals. The objectives of the program are to provide healthful meals and  related nutrition supportive services to nutritionally at-risk older persons in  the community. As an integral component of a comprehensive and coordinated home  and community-based service system, congregate and home-delivered nutrition  services serve different populations and may therefore have different outcomes for each program and the individuals served by each program.

However, both congregate and home-delivered programs share some of the same objectives which address food security and health needs of older persons such as providing basic food assistance through the provision of nourishing  meals, maintaining or improving individual nutritional status through the provision of a significant amount of essential nutrients in a meal, promoting healthy food and lifestyle choices through nutrition education and nutrition  counseling, reducing social isolation through participation at a congregate site  or through contact with the service delivery personnel, and linking older  persons to other home and community-based services and programs. Although both programs assist caregivers of functionally-impaired older persons, there is greater caregiver assistance through the provision of an in-home service such as  home-delivered meals. Although difficult to measure, services of the ENP assist older persons in remaining independent and at home, slow the progression of functional impairments, help avoid premature nursing home placement, prevent and  treat nutrition related conditions and diseases, speed recovery from illness and assist in limiting the use of more expensive health care services. 

Elderly Nutrition Program Evaluation: In order to better understand the  ENP as well as to comply with Congressional mandates, the AoA contracted with  Mathematica Policy Research, Inc. to conduct the ENP Evaluation. The ENP Evaluation results are due to the AoA in fall of 1995. The ENP evaluation will: Describe participant characteristics and assess program targeting; determine  impacts on participants, both dietary and opportunities for socialization;  describe and assess program administration and service delivery; and describe  and assess funding sources and funding shifts.

These findings will provide a starting point for the AoA, the Council, and the aging network in the development of performance measures for the ENP in  order to implement GPRA.

National Aging Program Information System (NAPIS): In response for the need for better data and Congressional mandates, the AoA is in the process of changing its data collection system. The proposed National Aging Program  Information System (NAPIS) State Program Report (SPR) is also an essential  component for the implementation of GPRA. NAPIS SPR will allow the AoA to  improve the accuracy of the data collected on participants, services, and  expenditures, enhance analysis of program performance, and provide information to improve service targeting to more at-risk older persons. This improved program output information can be combined with the results of evaluation studies, and other existing research on the effects of nutrition services to  develop methodologies to produce outcome measures required by GPRA and  envisioned by Performance Partnerships. The development of outcome measures will  likely need to be service by service and will probably need to vary to  accommodate program differences at the state and community level. Since  nutrition services are funded jointly or separately at State and community levels by other funds such as Medicare, Medicaid, Social Services Block Grants,  the development of outcome measures for these services cuts across Health and  Human Services operating divisions.

DISCUSSION: The tasks of allocating limited resources at a time of increasing service needs, assuring effective, quality services to the targeted populations at a reasonable cost, and improving program accountability is dependent on the development of results-oriented management practices including the development of good performance measures.

A good performance measure is: Driven by goals and objectives; clearly defined and can be applied consistently across organizations; has a numerator  and a denominator; and uses reliable data that is available or can be obtained cost-effectively.

Characteristics of a good performance measure include usefulness,  reliability, validity, practicality, consistency, and balance. After a  performance measure is developed and used, it must also be subsequently evaluated to determine it appropriately meets the need and provides the  necessary information for policy and decision makers to use. There are various  types of measures including: Input (the resources used to produce the result), process (the activities and tasks essential to produce the result), output (the  products and services produced), and outcome (the impact on the participant or  program).

In addition to the listed measures, there are other kinds of measures such measures for operations, quality, customer service and satisfaction, efficiency  and effectiveness. However, the GPRA and Performance Partnerships stress outcome measures for results-oriented management.

There is often little difficulty in quantifying both the input and process measures for a program because these are relatively straightforward. However, determining and quantifying the output and outcome measures for Federal programs are considerably more difficult. Direct Federal accountability is lessened because non-Federal parties such as States, Tribes, area agencies on aging and local service providers are responsible for the administration and operation of  the ENP. Because the reporting burden for a Federal program must be minimized,  complete information may not be available. Also, the results of a Federal program are frequently not immediately evident and can only be determined by a formal program evaluation which may be infrequent. The outcome for a program may  not be only the result of one agency but may be a result of a cross-agency program or policy and assigning the relative contributions or responsibilities to individual programs may be difficult and complex.

As the ENP has diversified and changed in response to demographic, service delivery, service system and health care system changes, State and local needs,  there has been limited national dialogue and limited consensus regarding the national program goals, objectives, outcomes or impacts. As a Federally-funded,  State and Tribe administered program that is responsive to State, Tribal and local needs, there is a great deal of diversity regarding program goals, administration, operation, and interaction with other funding sources. The AoA,  the Council, and the aging network are just now beginning that dialogue.  Together with the information from existing research, from NAPIS, the ENP  Evaluation and the dialogue with the Council and the aging network, the AoA will begin to define national program objectives, output, and outcome measures and determine how to incorporate an on-going mechanism to evaluate program impact on  older individuals.

SUMMARY: The AoA is required by GPRA to develop  outcome measures for results-oriented management of the ENP. The AoA task of  developing outcome measures for the ENP is aided by the data available from the ENP Evaluation and NAPIS. A primary responsibility of the Council is to assist  the Assistant Secretary for Aging and the AoA in this task by providing  recommendations regarding performance outcome measures.