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Nutrition

Evaluations Report

IV. TITLE III PROGRAM ADMINISTRATION AND SERVICE DELIVERY

D. INTERAGENCY RELATIONSHIPS

In order for the ENP to deliver nutrition services to participants successfully, the various agencies within the administrative hierarchy must understand their programmatic responsibilities under the OAA and successfully execute them. One important aspect of this process is for agencies within the aging network to both provide and receive information, in the form of technical assistance and training. An additional aspect is for agencies to monitor and assess the actions and performance of subordinate agencies in the program hierarchy. This section explores these issues on the basis of agency survey data. The first subsection examines technical assistance and training among the agencies in the aging network, as well as agencies’ perceptions about whether they receive adequate technical assistance and training. The second subsection examines monitoring and assessment activities.

1. Technical Assistance and Training

For each administrative level, the examination of technical assistance and training needs focuses on the relationship between the agencies in one level and the agencies immediately above it in the administrative hierarchy.

Technical Assistance and Training Received by SUAs from the AoA. Eighty percent of SUAs reported receiving at least some technical assistance from the AoA during the past year (Table IV.19). [ Technical assistance is defined as "clarifying advice or information received in person, by mail, or over the telephone. " ] Of those receiving technical assistance, about half received it on 5 or fewer separate days; 10 percent reported receiving technical assistance on 40 or more separate days (not shown). The median number of separate days of technical assistance for all SUAs is two. Somewhat fewer than half of the SUAs reported receiving any training from central or regional AoA staff in the previous year. [ Training is defined as "formal skills instruction, received either in person, by mail, or over the telephone. " ] The median number of separate days of training for all SUAs was thus zero. Overall, 84 percent of SUAs mentioned one or more areas in which they needed more technical assistance or training from the AoA.

TABLE IV.19

TECHNICAL ASSISTANCE AND TRAINING EXPERIENCES AND NEEDS OF TITLE III AGENCIES

(Percentages)


Technical Assistance and Training


Received by SUAs

from AoA

Received by AAAs

from SUAs

Received by Projects

from AAAs

Received Technical Assistance During the Past Year

80

89

81

Median Number of Days of Technical Assistance Received

2

2

2

Received Training During the Past Year

45

81

76

Median Number of Days of Training Received

0

2

2

Need More Technical Assistance or Training

84

50

48

Unweighted Sample Size

55

401

242

Source: Elderly Nutrition Program Evaluation; SUA, AAA, and Nutrition Project surveys; weighted tabulations

a Technical assistance refers to clarifying information or advice received either over the telephone, in person, or through written documents.

b Training refers to formal skills instruction, either in person, by mail, or over the telephone.

Technical Assistance and Training Received by AAAs from SUAs. Eighty-nine percent of AAAs reported receiving at least some technical assistance from the SUAs during the past year (Table IV.19). The median number of separate days of technical assistance for all AAAs was two. Eighty-one percent of AAAs reported receiving any training from SUA staff in the previous year. The median number of separate days of training for all AAAs also equaled two. Overall, 50 percent of AAAs mentioned one or more areas in which they needed more technical assistance or training from SUAs.

Technical Assistance and Training Received by Nutrition Projects from AAAs. Of the nutrition projects surveyed, 81 percent reported receiving technical assistance from AAAs on one or more separate days during the past year (Table IV.19). Three-quarters reported receiving training during the past year. The median number of separate days of technical assistance equaled two, as did the median number of days of training. A little under half of the projects reported one or more areas in which they needed additional technical assistance or training from AAAs.

Technical Assistance and Training Needs. Respondents at the SUAs, AAAs, and nutrition projects were asked an open-ended question about what types of additional training would be useful. Table IV.20 lists the range of areas in which the need for more assistance was mentioned. (Because the responses from each of these three levels were very similar, the table combines the replies across type of agency.) The open-ended responses were grouped according to broad categories, such as information about program policy (for example, new laws and reporting systems), operational issues (for example, menu planning and food preparation), and longer-range issues (for example, fundraising and linkages with other long-term care providers).

TABLE IV.20

AREAS IN WHICH MORE TRAINING AND TECHNICAL ASSISTANCE ARE NEEDED, AS REPORTED BY TITLE III AGENCY STAFF

Funding

Managing Funding (Cost Containment, Collection of Participant Contributions, Group Purchasing Practices, Competitive Purchasing, Developing Intrastate Funding Allocation Formula, Capital Procurement)

Identifying Additional Funding Sources (Fundraising, Grant Writing)

New Laws and Regulations

Complying with Reporting Requirements (Implementation and Use of NAPIS/Client Tracking System, Training Staff)

Interpreting New Laws and Regulations Since 1992, Developing Policies and Standards, Writing Program Policies and Procedures Manuals

Expanding Scope for Variation from Traditional Service Deliveries

Staffing and Personnel Issues

Training Staff on Use of New Food Service Equipment and Computers (Specifically for Site Directors, Cooks, and Drivers)

Recruiting and Managing Volunteers

Understanding General Policies and Procedures for Personnel

Managing Conflict, Stress

Interacting with Other Agencies

Monitoring Nutrition Projects, AAAs, Subcontractors

Verifying Meal Counts, Temperatures

Preparing Contracts/Bids, Issuing RFPs

Using Performance-Based Contracting

Evaluating Service Operations (Service Documentation)

USDA Program

Using Commodities Program Efficiently (Ordering, Availability)

Understanding USDA Retroactive Rate Increase Process, Reimbursement

Meals

Maintaining Food Safety and Sanitation (Requirements for Health Inspections, Concerns About Perishable Foods, Preventing Food-Borne Illnesses)

Procuring Food

Planning Menus (Meeting RDA Requirements and Special Dietary Needs of Elderly, Providing Meals for Different Groups, Substituting Meals)

Evaluating Meal Services (for Overall Quality, Special Diets)

Balancing Regulations for Nutrition Levels with Client Preferences

Finding and Using Economical Meal Choices

Controlling Portions

Other Nutrition Services

More Information on Procedures for Nutrition Information, Assessment, Counseling, and Screening (Especially for Malnutrition)

How Nutritional Needs Change as People Age

Latest Developments/Trends in Nutrition

Impact of Drugs on Nutritional Needs

Non-Nutritional Services

Mental Health Issues, Transportation Issues, Case Management, Alcoholism, HIV, Stress Management

Ways to Encourage Socialization, Intergenerational Activities

Information on Community-Based Care

Safety Issues

Training in CPR and First Aid, Emergency Situations

Preventing Contagious Diseases

Safety Requirements and Precautions for In-Home Visits

Maintaining Security at Sites, Fire Code Specifications

Outreach

How to Reach Targeted Populations (Minority Groups, Frail Individuals, Veterans, Low-Income Persons)

How to Make Outreach More Effective, Especially with Newer Senior Populations

How to Increase Congregate Meal Participation

Marketing Strategies, Gaining Media Support

Customer Relations

Dealing with Particular Problems or Needs, Difficult Clients

Training on Sensitivity Issues

Training on Multicultural Issues, Intergenerational Issues

Other Administrative Issues

Bookkeeping/Accounting

MIS Assistance

How Program Is Structured and Operates

Paperwork Conformity and Efficiency

Legal Issues Regarding Serving or Not Serving Clients

Inventory Control

Waste Reduction

Other Topics

Initiatives in Other States, Idea Sharing

Procedures for Statistical Data Gathering

Ways to Revitalize Senior Centers and Improve Site Accessibility

Use and Implications of Medicaid Waivers

Special Issues Regarding Breakfast Service

Source: Elderly Nutrition Program Evaluation, SUA, AAA, and Title III Nutrition Project surveys.

Note: Information in this table is meant to indicate the broad areas in which agency staff mentioned they would like additional training and technical assistance.

NAPIS = National Aging Program Information System.

SUA answers to the need for more training covered a broad range of categories, including information about program policy (such as the OAA and new laws and reporting systems), operational issues (menu planning, targeting, and nutritional counseling), and longer-range issues (fundraising and cost containment, recent advances in nutrition for elderly people, and research on the impact of changes in emphasis from congregate to home-delivered systems). Areas in which more assistance was desired overlapped considerably. These areas included financial management and cost-saving techniques, monitoring and evaluating AAAs and nutrition projects, implementing the new reporting system, USDA programs, screening, assessment and counseling guidelines, and targeting issues.

Those AAAs wanting more assistance reported that further training was needed in monitoring food handlers and nutrition projects, implementing targeting for special populations, implementing and using the National Aging Program Information System (NAPIS), and understanding existing and new regulations. Menu planning and volunteer recruitment strategies were also mentioned as areas in which further training could be useful. Of the AAAs wanting more technical assistance, some common areas of need were menu planning, nutrition education, and effective monitoring methods.

The primary areas in which nutrition projects would like more training include meal planning and nutrition (such as ensuring proper nutritional content for elderly people with special needs, using USDA commodities, diversifying menus, and preparing food), sanitation issues (such as monitoring temperatures), changes in regulations and reporting (recordkeeping and other computer assistance), recruiting and outreach to potential participants (particularly minorities), recruiting and managing volunteers, and assistance in budget management (for example, gaining a better understanding of funding sources generally and guidance on fund-raising strategies). Survey respondents mentioned similar topics when asked forareas in which they would like more technical assistance. A few nutrition projects also mentioned case management issues, legal issues for the project and board of directors, and assistance in grant writing.

2. Monitoring and Assessment

Another form of agency interaction involves direct monitoring and on-site assessments conducted by various levels of the network. Next, we describe SUA monitoring and assessment of AAAs and nutrition projects, and then AAA monitoring and assessment of nutrition projects.

SUA Monitoring and Assessment Activities. The statutory basis for the expectation that SUAs monitor and assess the activities of AAAs is found in Section 305(a)(1)(c) of the OAA, which states that SUAs "will conduct periodic evaluations of, and public hearings on, activities and projects carried out under the State plan." Through the years, AoA and many SUAs have interpreted and instituted the practice of conducting "an annual on-site assessment" of AAAs to evaluate their programs and activities (U.S. Department of Health and Human Services, Administration on Aging and Office of Inspector General, April 1993). Of the SUAs that are not single-state planning and service areas, virtually all of them--98 percent--actively assess or monitor the AAAs that they administer (Table IV.21). [ This part of the analysis excludes the 14 SUAs in single-state planning and service areas, in which there is no AAA and the SUA essentially performs the functions of the AAA. The analysis of SUA monitoring and assessment of nutrition projects are based on all SUAs, including the single-state planning and service areas. ] All of the SUAs that do such monitoring (or 98 percent of all SUAs) conduct on-site assessments of AAAs. On average, each AAA is visited four times a year. More than 85 percent of SUAs that monitor (or 81 percent of all SUAs that are not single-state planning and service areas) require AAAs to submit written narrative reports for state agency review. Respondents reported receiving an average of a little more than three written narrative each AAA per year. Virtually all SUAs also used statistical and fiscal reports as monitoring devices, at an average of nearly six and eight times per year, respectively.

TABLE IV.21

SUA ASSESSMENT AND MONITORING OF AAAs AND NUTRITION PROJECTS

(Percentages, Unless Stated Otherwise)


SUA Assessment and Monitoring of AAAs


SUA Assessment and Monitoring of Nutrition Projects

Assessment/Monitoring Method

All

SUAsa

SUAs that Monitor

or Assess


All

SUAsa

Those that Monitor

or Assess

Assess or Monitor

98

--


65

--

Site Visits






Conduct On-Site Assessments

98

100


61

94

Average Number of Times Conduct On-Site Assessments

3.9

4.0


4.0

6.5

If Had Choice, Would Conduct On-Site Assessments:






More frequently

42

43


43

70

About the same

52

52


18

30

Less frequently

4

5


*

*

Not asked

2

--


39

--

Written Narrative Performance Reports






Review Narrative Written Performance Reports

81

85


54

85

Average Number of Times Require Reports Submitted for Review

2.7

3.3


3.0

5.6

If Had Choice, Would Request Narrative Reports:






More frequently

23

29


15

28

About the same

*

*


37

69

Less frequently

58

71


2

3

Not asked

19

--


46

--

Written Statistical Performance Reports






Review Statistical Reports

96

98


50

82

Average Number of Times Require Reports Submitted for Review

6.4

6.7


3.9

7.9

If Had Choice, Would Request Statistical Reports:






More frequently

6

7


10

20

About the same

81

83


38

76

Less frequently

9

10


2

4

Not asked

4

--


50

--

Written Fiscal Reports






Review Fiscal Reports

98

100


50

82

Average Number of Times Require Fiscal Reports Submitted for Review

7.5

7.6


3.9

7.8

If Had Choice, Would Require Fiscal Reports:






More frequently

5

5


5

11

About the same

91

93


45

89

Less frequently

2

2


*

*

Not asked

2

--


50

--

Sample Size

43

42


54

54

Source:Elderly Nutrition Program Evaluation, SUA survey.

aSingle-state planning and service area SUAs are excluded since they function as the AAAs.

* = Less than 0.5 percent.

In general, the majority of SUAs believe that they have sufficient resources for the various kinds of monitoring they conduct, characterizing the frequency of monitoring as "about right." Depending on the monitoring method used, "about right" accounted for 52 to 93 percent of SUA responses. A substantial proportion of SUAs--43 percent--indicated that they wished they could perform on-site monitoring more frequently. Relatively few SUAs want to monitor less frequently, although about 10 percent of respondents that review statistical reports thought the number currently required is excessive.

In addition to monitoring AAAs, most SUAs monitor nutrition projects. Almost two-thirds of the SUAs report directly monitoring nutrition projects in their jurisdictions (Table IV.21). Among those conducting such monitoring, most reported using each of the four monitoring tools discussed earlier. Almost 70 percent of SUAs would like to conduct on-site visits of nutrition projects more frequently. Most reported being satisfied with the frequency of their other monitoring work. A slightly smaller percentage of SUAs use statistical or fiscal reports to monitor nutrition projects; when any method is used, it is employed slightly more frequently for monitoring nutrition projects than for monitoring AAAs.

SUA respondents were asked to indicate the most common deficiencies they found during their monitoring and assessment activities. Summarized in Table IV.22, these results illustrate the types of problems that arise in ENP operations. Between 20 and 30 percent of SUAs indicated the following types of problems: an inadequate number of staff or lack of staff with specific nutrition credentials, lack of resources, and food safety and sanitation issues. In addition, SUAs mentioned a wide range of other problems, ranging from problems with procurement practices or recordkeeping, to failure to target services and determine eligibility appropriately, to problems meeting RDA requirements. Other problems pertain to service delivery, such as an insufficient amount of nutrition education, inaccessible meal sites, or insufficient variety and temperature regulation of meals.

TABLE IV.22

DEFICIENCIES IN SUAs’ LAST ASSESSMENT OF AAAs OR NUTRITION PROJECTS

(Percentages)

Found Deficiencies in Last Assessment of AAA or Projects

96

Common Deficiencies


Food safety and sanitation problems

27

Lack of resources

27

Inadequate number of staff with dietetic/nutrition credentials

22

Inadequate number of staff

20

Inadequate nutrition provider assessments by AAAs

9

Sample Size

55

Source:Elderly Nutrition Program Evaluation, SUA survey.

3 .AAA Monitoring of Nutrition Projects

Section 306(a)(6)(A) of the OAA stipulates that the Area Agency on Aging will conduct periodic evaluations of, and public hearings on, activities carried out under its area plan.

Of AAAs that administer one or more nutrition projects (excluding AAAs that are the only nutrition project in their planning and service area), virtually all of them--99 percent--monitor or assess the nutrition projects they supervise (Table IV.23). [ AAAs may directly provide nutrition services in their planning and service area. The analysis in this section excludes AAAs that are the only nutrition project in their planning and service area.] Of those AAAs that monitor nutrition projects, all reported on-site visits to nutrition projects in their planning and service area. Most that perform on-site visits do so almost once per month (the average number of on-site assessments per project is 11.2 per year). Although the majority (59 percent) of AAAs report that the frequency with which they visit projects is about right, two-fifths would like to conduct more on-site visits to their nutrition projects. Ninety-seven percent of AAAs that monitor require projects to submit fiscal reports, and 93 percent require them to submit statistical reports. Virtually all (more than 90 percent) are satisfied with the frequency with which they require these reports to be submitted. Narrative written reports are used less frequently, but still by 85 percent of AAAs. About three-quarters of AAAs are satisfied with the level of this monitoring that they perform, but about one-quarter would prefer increased monitoring. Overall, it appears that AAAs perform an extensive level of monitoring for the nutrition projects they supervise, and most are satisfied with the intensity of monitoring they perform.

TABLE IV.23

AAA ASSESSMENT AND MONITORING OF NUTRITION PROJECTS

(Percentages, Unless Stated Otherwise)


AAA Assessment and Monitoring of Nutrition Projects

Assessment/Monitoring Method

All AAAs a

AAAs that Monitor

or Assess

Assess or Monitor

99

--

Site Visits



Conduct On-Site Assessments

99

100

Average Number of Times Per Year Conduct On-Site Assessments

11.1

11.2

If Had Choice, Would Conduct On-Site Assessments:



More frequently

39

39

About the same

59

60

Less frequently

1

1

Not asked

1

--

Written Narrative Performance Reports



Review Narrative Written Performance Reports

84

85

Average Number of Times Per Year Require Reports Submitted for Review

5.6

6.7

If Had Choice, Would Request Narrative Reports:



More frequently

19

23

About the same

62

74

Less frequently

3

3

Not asked

16

--

Written Statistical Performance Reports



Review Statistical Reports

92

93

Average Number of Times Per Year Require Reports Submitted for Review

16.7

18.2

If Had Choice, Would Request Statistical Reports:



More frequently

5

6

About the same

84

91

Less frequently

3

3

Not asked

8

--

Written Fiscal Reports



Review Fiscal Reports

96

97

Average Number of Times Per Year Require Fiscal Reports Submitted for Review

9.2

9.6

If Had Choice, Would Require Fiscal Reports:



More frequently

6

6

About the same

88

92

Less frequently

2

2

Not asked

4

--

Unweighted Sample Size

341

337

Source: Elderly Nutrition Program Evaluation, AAA survey, weighted tabulations.

a AAAs that are the only nutrition project in the planning and service area are excluded.