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Administration on Aging
National Nutrition Advisory Council  Meeting
September 12 and 13, 1995
Doubletree Hotel,  Arlington, Virginia

Drafted by Joseph M. Carlin, M.S.,  R.D.
Region I Nutritionist, Administration on  Aging

ISSUE: The issue facing the Administration on  Aging (AoA) is how does the AoA with the assistance of the National Nutrition  Advisory Council (Council) develop core standards and guidelines to ensure  efficient and effective delivery of quality nutrition services provided through  the Elderly Nutrition Program (ENP) of the Older Americans Act (OAA).

BACKGROUND: Standards for the delivery of home  and community nutrition services for the elderly have existed since the creation of the ENP under Title VII of the Older Americans Act in 1972 (Public Law  92-258). This legislation funded a system for the provision of both congregate  and home delivered nutrition services to the elderly. For almost 25 years the  ENP has been a highly visible and popular service program for the nation's elderly. Almost one year before the first meals were served in the program,  "Standards for Nutrition Projects" were published in the Federal Register (Vol.37(162):16848-49, August 19, 1972). These standards were based upon the experience of Title IV demonstrations programs that had been experimenting since  1968 with various methods of delivering nutrition services to the  elderly.

Some of these early standards were very prescriptive and offered nutrition service providers (NSP) little flexibility. For example, during the first five years of the program only hot meals could be served. To implement standards,  State agency on aging and NSP personnel had a rich assortment of resources to  call upon including the following sources:

  • The Title VII section of The OAA of 1965 as amended (March, 1972).
    For example, the OAA stated that "each meal served must contain at least 1/3 of the current Recommended Dietary Allowances (RDAs)."
  • Rules and Regulations for the Title VII program (August, 1972).
    For example, Federal regulations stated that for the purpose of this program, a hot meal "is one in which the principal food item of the meal is hot at the time of serving."
  • Manual of Policies and Procedures for Title VII December 1972).
    This 236 page manual expanded upon the standards in the Federal  regulations. For example, under meal planning standards, "menus must be planned  for a minimum of four weeks, certified in writing by the  dietitian/nutritionist...and submitted to the State agency for review..."
  • Guide to Effective Project Operation (April 1973).
    This 500-page manual, affectionately called the "Green Guide," because of its dark green vinyl cover, was the bible for the ENP program for almost 20 years. It  repeated the standards found in the OAA, the Regulations and the Manual of  Policies and Procedures but presented them in a user friendly format. These  standards were developed and published before the first Title VII nutrition  services were provided by the States in July, 1973.

During this early period of experimentation and growth, State agencies on  aging and NSPs had access to a wealth of additional resources to help them meet  OAA standards.

Between 1973 and 1976 the AoA funded five nutrition training centers to  assist States and NSPs to meet OAA standards. All Title VII directors attended a  two-week residential training program to assist them in meeting OAA  standards.

Throughout the 1970s AoA published a large body of Program Instructions  (PIs), Information Memorandum (IMs), and other technical assistance documents to  assist States and NSPs meet OAA standards.

During the 1970s AoA had a staff of 14 dietitians/ nutritionists, one in each of the 10 Regional Offices, to provide extensive on-site technical  assistance and consultation to the States and NSPs on how best to meet OAA  standards.

The first major change in standards came when the ENP was folded into the  Title III program with the 1978 amendments to the OAA. For example, it wasn't  until 1978 that cold, chilled, frozen or shelf stable meals could be provided to recipients. These amendments established separate funding for congregate and home-delivered nutrition services.

During the 1980s AoA priorities for the ENP did not focus on nutrition standards. For guidance, States and NSPs were instructed to refer to the OAA. Toward the close of the 1980s some personnel in the ENP found the OAA provision that "each meal be 1/3 of the RDA" to be an obstacle to quality meal service for programs that wanted to serve more than one meal per day. For example, NSPs  found it easy to plan a two-meal per day service that met 2/3rds of the RDA but a two-meal a day program, with each meal being 1/3 or more of the RDA, was more expensive. As a result, the 1992 amendments to the OAA corrected this problem  and made it easier and cheaper to develop two- and three-meal-a-day programs. Additional guidance for implementation of these OAA requirements in the form of  Federal regulations, PIs, or IMs have not been published. When AoA surveyed States in 1994 to determine their compliance with the provisions of the OAA it was found that 98% of the States had written guidance for the OAA standard that  if one meal is served, it must provide 1/3 of the RDA. However, only 27 of the 53 States and Territories (51%) surveyed provided written guidance on the  service of two meals in a day.

The 1992 amendments to the OAA included an additional standard that meals  provided through the program must comply with the Dietary Guidelines for Americans, published by the Secretary and the Secretary of Health and Human  Services and the Secretary of Agriculture. No additional Federal guidance in the form of regulations, PIs, or IMs has been issued.

In the early 1980s the National Association of Nutrition and Aging Services Programs (NANASP) published Congregate Nutrition Services Program  Standards (October, 1983) and Home-Delivered Nutrition Services Program  Standards (January 1984). In the foreword to these documents William R. Moyer,  President of NANASP states that these documents were developed "in response to a need to maintain and insure quality nutrition services for the nation's elderly."

In the late 1980s members of the Gerontological Nutritionists, a practice  group of The American Dietetic Association published Effective Menu Planning for  the Elderly Nutrition Program. In the foreword to this manual the Commissioner of the AoA stated that the information in the manual "is essential for those who  are responsible for planning, monitoring, or ensuring high-quality meal services to the elderly." The appendix included nutrition standards and menu policies  from five states. The preface to this manual stated that if the practitioner followed the ideas in this manual "high standards of menu planning can be met in  different ethnic and regional settings."

In September, 1993, the AoA convened a workgroup to recommend a process  for the development of guidelines/standards/criteria for the ENP. Participants at the meeting represented regional, State, Tribal, area agency on aging (AAA), and NSP organizations. The workgroup produced recommendations to the AoA which are attached to this issue paper as Exhibit 1. Recommendations. These  recommendations were not implemented.

In addition to these documents, many States produce their own operation  manuals or policy and procedure manuals, or minimum standards for operation that are used as the basis for ensuring compliance with the OAA standards. These documents vary widely in their prescriptiveness, specificity flexibility,  accountability and interpretation.

The existence of the documents cited above indicate that there was a need  for a national set of standards and guidelines that States, Tribes, AAAs, and  NSPs can use to measure their progress against.

DISCUSSION: The Older Americans Act Amendments  of 1992 [Sec. 206(g)(2)(A)(i)] mandates the establishment of an advisory council to develop recommendations for guidelines on efficiency and quality in  furnishing nutrition services under Title III. The convening of this advisory council is an affirmation that standards for the ENP are needed. A primary  function of the Council is to develop these recommendations.

A similar provision, but less directive, was included in the 1978  amendments to the Older Americans Act but never acted upon.

The early years (1973 - 1981) of the ENP can be characterized as a period  of experimentation and accelerated growth. Only a small, unorganized pool of  qualified gerontological nutritionists existed then and States looked to the Federal government for direction. Only a few formal studies of the nutrition program existed and there was no consensus on the energy and nutrient needs of the elderly participants.

The next stage in the development of ENP can be characterized as a period  of independence, stability and self reliance (1982 -1992). Less information was collected from the States on nutrition services and States turned less to the  Federal government for direction. This period saw an explosion in the use of computers and a growing consensus on the nutritional needs of the  elderly.

The ENP is in a transition phase from a characterization as simply a national network of meal providers to a Federal/State partnership to support the  provision of nutrition services to the elderly as part of a system of home and community based care. This system is characterized by maximum State flexibility  in the design of community based nutrition services, increased use of technology and communication systems and a reliance upon highly trained and certified health care specialists applying standards of care based upon and expanding  research base.

As a Federally-funded, State-administered program, the ENP has diversified and changed in response to demographic, service delivery, service system and health care system changes, State and local needs, and funding constraints. The system is characterized by great diversity in kinds of services provided as well  as the sophistication regarding nutrition services between and among States,  AAAs, and NSPs. Although OAA funding did not increase during the 1980s,  nutrition services continued to grow through the infusion of other funding  streams. Although the primary source of funding for most NSPs remains OAA  funding, there is wide-spread use of other funding sources which may have other  service standard requirements such as State funds, Medicaid waiver funds, and  social service block grant funds. Although this wide-spread diversity presents a barrier to a single way of ENP implementation as described in the "Green Guide",  it strengthens the ENP by ensuring that it is flexible enough to meet changing local needs.

The current political climate at a Federal level is marked by an atmosphere that emphasizes decreased Federal regulation and prescriptiveness as  well as increased State flexibility and latitude. The emphasis has shifted from  process orientation to results management. Yet a concern for  standards/guidelines to ensure quality and provide a measure for success  remains. The challenge to the AoA, Council, and the aging network is how to  ensure a minimum consistent level of quality that is science based and yet  provide for innovation and flexibility to meet changing individual and system  needs.

SUMMARY: As required by the OAA, the AoA has established the Council to develop recommendations for the Assistant Secretary  for Aging and the AoA on guidelines on efficiency and quality in furnishing nutrition services. In a time of increasing diversity, flexibility, and multiple  funding streams, the challenge to the AoA, the Council, and the aging network is to ensure a minimum consistent level of quality that is science based and yet  provide for innovation and flexibility to meet changing individual and system needs. Completion of this task will allow the AoA and the aging network to assure Congress and the American taxpayer that their tax dollar is spent is a worthwhile way.