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Nutrition

Evaluations Report

IV. TITLE III PROGRAM ADMINISTRATION AND SERVICE DELIVERY

E. RELATIONSHIPS WITH OTHER AGENCIES

For the ENP to operate as effectively as possible, its services must be carefully coordinated with those of other agencies that provide assistance to elderly people. In this section, we focus on two sets of interactions with non-ENP agencies that are particularly relevant to the ENP program:

1. The integration of the program with home- and community-based long-term care initiatives

2. The program’s use of USDA commodities and cash in lieu of commodities

1. Integration with Home and Community-Based Long-Term Care Services

With the aging of the U.S. population, policymakers are giving increased priority to identifying the most effective systems of home- and community-based long-term care services that allow older people to remain in their communities and avoid unnecessary and costly institutionalization. The ENP plays an important role in the emerging structure of home and community-based long-term care by promoting optimal nutritional status in older people through the delivery of congregate and, when appropriate, home-delivered meals and related supportive services. The maintenance of nutritional well-being, particularly in advanced age, is known to mitigate existing health problems, enhance the management of many chronic conditions, prevent adverse consequences of acute and chronic illnesses, accelerate wound healing and recovery from trauma, improve functional capacity, and extend years of healthy living (see, for example, Posner et al. 1994). In Section B, we described services ENP agencies often have available. These include nutrition-related services, such as nutritional assessment, education, and counseling, and non-nutritional services, including transportation assistance to buy groceries or receive medical care, legal assistance, and information and referral to other agencies. The services provided by Title III programs could function independently of a home and community-based long-term care system but, if integrated, could help in establishing a continuum of long-term care and in meeting the long-term care system’s objectives. In this section, we explore activities at various levels of the ENP related to the development of home and community-based long-term care, particularly integrating ENP with the work of other long-term care providers.

SUA Level. Forty-eight SUAs responded to an open-ended survey question about ongoing efforts to integrate the Title III nutrition programs with home- and community-based long-term care activities. These responses describe the SUAs’ involvement in the provision of home and community-based long-term care services and contribute to our understanding of ongoing or planned activities to integrate Title III programs with these services in each state.

The SUAs appear to be making substantial efforts to integrate their Title III programs with home and community-based long-term care systems or services (Table IV.24). This integration occurs either through direct provision of long-term care services, including nutrition services, and intentional integration of these services with the ENP, or through the states’ role in the administration and coordination of statewide plans for long-term care and the allocation of related funding. Some SUAs employ agency staff who deliver one or more home and community-based long-term care services directly; others provide funding to other state agencies or public and private entities to deliver specific services in an integrated fashion.

The SUAs described involvement in a wide range of ongoing home and community-based long-term care services and programs. Those currently funded or provided directly by SUA staff include statewide elder needs assessment, direct case planning and management (including arranging older clients’ receipt of needed health and supervised social programs), elder housing, adult protective and day care services, hospice programs, homemaker and personal attendant care, seven-day meal services, Medicaid waiver programs to fund congregate and home-delivered meals in a variety of settings (discussed in more detail next), information and referral, senior recreational activities, and pharmaceutical management services. SUAs also may oversee long-term care services coordinated by the AAAs within their state.

In addition to funding home and community-based long-term care services or providing them directly, SUAs describe ongoing administrative efforts to coordinate the Title III program and other long-term care activities at the state and local level, including developing policies to integrate services more fully, applying for Medicaid waivers that address housing issues (such as home repair), securing USDA commodities, facilitating reimbursement for adult day care meals, linking Title III state long-term care plans and services, and developing formal, integrated networks of long-term care and Title III service providers

TABLE IV.8

TITLE III SERVICES OFFERED BY NUTRITION PROJECTSa

(Percentages)


Services to

Congregate Meal

Participantsb

Services to Home-Delivered Meal Participantsc

All

Projects

Congregate Meals

100

--

95

Home-Delivered Meals

--

100

81

Nutrition Education

88

81

87

Nutrition Screening

54

54

55

Nutrition Assessment

31

35

36

Nutrition Counseling

49

43

50

Transportation to and from Meal Site

68

--

68d

Other Transportatione

57

58

54

Recreation and Social Activities

69

--

69d

Other Counseling

53

50

51

Information and Referral

85

84

84

Coordination with Other Health and Medical Service Agencies

40

35

39

Personal Care Service

4

5

4

Homemaker Services

12

14

12

Home Health Aid Services

5

6

5

Adult Day Care/Adult Day Health Services

4

5

4

Case Management

4

4

4

Outreach

9

11

9

Other Services

12

12

12

Unweighted Sample Size

229

208

242

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

a Services available through the nutrition project that are funded in whole or in part by Title III funds.

b Projects providing congregate services.

c Projects providing home-delivered services.

d Calculated only for those projects with congregate programs, since only projects providing congregate services were asked the question.

e Includes all assisted or nonassisted transportation services other than transportation between meal sites and participants’ homes.

Fifty SUAs responded to the question on key policy issues that need to be addressed to integrate Title III and home and community-based long-term care services more fully (Table IV.24). Common issues are inadequate federal, state, and/or local funding and differences in policies, regulations, and requirements across programs and agencies. SUAs also reported resource limitations, including inadequate numbers of qualified staff, service providers, and community-based facilities, as barriers to integration. Some SUAs reported lack of central coordination of long-term care services in their states as a major policy issue. This category includes responses such as lack of the following: (1) a coordinated delivery system or "one-stop shopping" for services; (2) an integrated case management strategy; (3) a single case management entry point; and (4) specifications of who or what entity will coordinate long-term care services. Other funding issues, such as coordination of funding, inflexibility in regulations or policies to determine AAAs’ allocation of funds, and limited success in securing waivers, were also cited. The following barriers were reported less frequently: limited access to services; misunderstanding of the Title III program (lack of recognition in the long-term care system that nutrition services are a critical component of the system, limited recognition by long-term care management of the nutritional needs of older people, and so on); lack of formal interaction among agencies; and health care reform.

AAA Level. There were 327 respondents to the question about ongoing AAA activities to integrate Title III nutrition program services with home- and community-based long-term care programs and services. These responses describe the range of long-term care services that are presently available at the regional and local level and provide an indication of AAAs’ role in administering and delivering these programs and services, including integrating Title III and other long-term care services and programs.

Many AAAs appear to be heavily involved in long-term care activities in their state planning regions and/or territories (Table IV.25). Some report playing a major leadership role or functioning as the primary provider of home and community-based long-term care services in their planning and service areas. AAAs may employ staff in case management roles to plan, coordinate, and manage long-term care services for older clients in their service areas and may also coordinate regional/service area funding for these services. Many AAAs report specific ongoing efforts to integrate Title III services with other home- and community-based long-term care programs. These efforts include arranging congregate or home-delivered meals for clients of a variety of long-term care services; linking Title III services with nursing homes; addressing needs for other services among Title III clients; coordinating home-delivered meals and other in-home services; providing information and referral across programs and services; providing meals for adult day care clients; and supplying ombudsman services, health promotion activities, transportation, health screening, outreach, respite care, and nutrition education for Title III clients.

TABLE IV.25

RESPONSE CATEGORIES FOR OPEN-ENDED QUESTIONS ON INTEGRATING TITLE III WITH OTHER HOME AND COMMUNITY-BASED LONG-TERM CARE PROVIDERS AT AAA LEVEL

Efforts to Integrate with Home and Community-Based Long-Term Care Programsa

Serve as leader/primary provider of case management

Provide specific long-term care services

Coordinate Title III with other services

Coordinate regional funding for long-term care services

Have work in progress/future goals

Ways Title III Could Be More Fully Integrated with Other Home and Community-Based Long-Term Care Servicesb

Improve coordination/integration among agencies

Give leadership authority to the AAA

Increase funding

Increase services provided

Modify rules and regulations

Other

Source: Elderly Nutrition Program Evaluation, AAA survey.

a The items listed represent broad categories of answers to an open-ended question on efforts the agency has made to integrate Title III services with home- or community-based long-term care programs.

b The items listed represent broad categories of answers to an open-ended question on how the Title III program could be more fully integrated with home-or community-based long-term care operations.

Many AAAs identified other providers of long-term care services with which they coordinate Title III and other long-term care services. Coordination is, in some planning and service areas, facilitated by a statewide long-term care program but is more commonly the result of AAA initiatives to work with the following types of providers: home health agencies; other home care service providers; hospitals; rehabilitation centers; nursing homes; health maintenance organizations; providers of services to those with Alzheimer’s disease; and other community-based social service agencies, such as adult day care programs. Some AAAs indicated that they have not yet initiated their plans to integrate Title III and other long-term care services (not shown). Most of these AAAs plan to focus on specific home- and community-based programs and services, including outreach activities, ombudsman programs, caregiver training programs, adult day care, Medicaid waiver programs for congregate and home-delivered meals, home care services, nursing homes, senior residences, and mental health programs.

A small proportion of AAAs believe that the home and community-based long-term care system is fully integrated with the Title III program in their areas, but most AAAs have a number of recommendations for closer interaction between Title III and other home- and community-based long-term care services (Table IV.25). The most frequent recommendations are administrative in nature and address further coordination and integration among agencies. Topics include consolidating efforts and minimizingduplication of services; creating a single funding source for long-term care services; establishing a single entry point, such as AAAs, for long-term or case management; creating mechanisms for improved communications and networking among providers; and increasing the consistency and flexibility in rules and regulations that govern long-term care programs and services, particularly eligibility requirements, to make coordination across agencies easier and eliminate service duplication. Some AAAs note that increased funding would facilitate the integration of Title III services with home and community-based long-term care and help them initiate or expand their role as direct providers of long-term care services. Some AAAs also indicated that integration of Title III and other long-term care services would be aided by increased funding for specific programs and services, including in-home services, congregate and home meals, case management, outreach, education and training, transportation, and Medicaid waiver programs. Miscellaneous recommendations for encouraging integration of Title III and other long-term care services include consolidating programs and providers into a single building, establishing contracts with other groups to provide community services, enacting health care reform, improving access to care, and developing a client-driven system of care.

Some 34 agencies responded to the question about future plans for integrating Title III services with other home- and community-based programs and services (not shown). Most AAAs intend to focus on specific programs and services, such as outreach programs, ombudsman programs, caregiver training, adult day care, Medicaid waiver programs for congregate and home-delivered meals, home care services, nursing homes, mental health services, and other state or county programs.

Nutrition Project Level. There were 144 responses at the nutrition project level to the question about ongoing activities to integrate Title III and home- or community-based long-term care programs and services. These responses reflect meal service providers’ perceptions of the Title III program’s role in long-term care, specific services and activities that make these roles possible, and barriers to integration of Title III and other services for the older population.

Nutrition projects clearly view themselves as an important component of the home and community-based long-term care system and report that they function as direct providers of meals, other Title III services, and other long-term care activities (Table IV.26). They often serve as an important link between clients and other providers in the long-term care network.

TABLE IV.26

RESPONSE CATEGORIES FOR OPEN-ENDED QUESTIONS ON INTEGRATING TITLE III WITH OTHER HOME AND COMMUNITY-BASED LONG-TERM CARE PROVIDERS AT NUTRITION PROJECT LEVEL

Efforts to Integrate with Home and Community-Based Long-Term Care Programsa

Involved with or provide case management

Coordinate Title III with other services

Provide specific long-term care services

Other

Working Relationships with Providers of Other Home and Community-Based Long-Term Care Servicesb

Good or excellent

Problem areas

Other

Source: Elderly Nutrition Program Evaluation, Nutrition Project survey.

a The items listed represent broad categories of answers to an open-ended question on efforts the agency has made to integrate Title III services with home- or community-based long-term care programs.

b The categories listed represent answers to an open-ended question on how the respondent would describe the agency’s working relationship with home- or community-based long-term care providers.

Most nutrition projects carry out specific activities in which they either directly provide their clients with needed home and community-based long-term care services or connect them with other providers of these services. Some nutrition projects provide direct case management for their clients or interact with AAA staff who are client case managers. In addition, nutrition projects directly provide services that included information and referral; congregate and home-delivered meals; transportation; adult day care; in-home services; outreach; and services involving nursing homes, hospitals, and housing programs.

Nutrition projects often reported involvement in collaborating with other local agencies to coordinate home and community-based long-term care services as well as in coordinating with statewide long-term care systems. Most nutrition projects reported that their working relationships with other home- or community-based long-term care providers are good to excellent. Problem areas mentioned included less than desirable interactions with skilled nursing care providers and hospital discharge planners, as well as difficulties interacting with service providers for disabled persons.

Medicaid Waiver Program. One very specific form of coordination between the ENP and home and community-based long-term care relates to funding for meals provided by ENP nutrition projects to elderly persons who receive services as part of a Medicaid waiver. As part of a coordinated system of services for Medicaid participants who are at risk of institutionalization, a state can obtain a Medicaid waiver, under which Medicaid funds can be used to pay for the costs of providing these participants with a number of services, including meals. At this point in time, however, few Medicaid waiver funds are used to support meal services. Thirty-one percent of the SUAs report that such waivers have been set up for home-delivered meals in their states (Table IV.27). A considerably smaller proportion of SUAs--seven percent--have such an arrangement in place for congregate meals. Understandably, states are more likely to have established the Medicaid waiver program for home-delivered meals, because these participants are more likely to be at risk of institutionalization than the typical congregate meal participant.

TABLE IV.27

USE OF MEDICAID WAIVERS TO PAY FOR MEALS PROVIDED BY TITLE III PROGRAMS

(Percentages)


SUAs

AAAs

Have Waiver that Allows Home-Delivered Meals to Be Paid for with Medicaid Funds

31

26

Average Percentage of Total Home-Delivered Meals Paid for with Medicaid Funds a

3.7

8.8

Have Waiver that Allows Congregate Meals to Be Paid for with Medicaid Funds

7

11

Average Percentage of Total Congregate Meals Paid for with Medicaid Funds a

0.0

0.5

If Arrangement in Place, Was Involved in Setting It Up

90

69

If No Such Arrangement, Involved in Discussions to Set One Up

44

41

Unweighted Sample Size

55

400

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

a In states with waiver arrangement for home-delivered or congregate meals.

Meals financed under a Medicaid waiver program are not technically Title III meals, but they may be produced and served by the same providers who participate in the ENP. SUAs with Medicaid waivers in place estimate that about four percent of all home-delivered meals are covered by the Medicaid waiver program. For reasons that are unclear, however, the corresponding percentage is zero for the few states with waivers for congregate meals.

In nearly 90 percent of the states with waiver programs, SUAs report involvement in establishing these programs. Furthermore, in 44 percent of the states currently without such arrangements, SUAs reported attempts to develop them.

Referral Sources. Another aspect of the integration of the ENP with other home- and community-based long-term care agencies is the extent to which Title III nutrition service providers get participant referrals from these agencies. Consistent with the results based on participants’ self-reported referral methods, Title III home-delivered meal programs rely heavily on hospitals/intermediate care facilities, medical doctors, and case management service agencies on one hand, and on referral from family, friends, or neighbors on the other. For 45 percent of all Title III nutrition projects that provide or arrange for home-delivered meals, hospitals or intermediate care facilities are the first or second most important source for referring participants into the home-delivered meals program; for 30 percent, medical doctors are either the first or second most important source (Table IV.28). In contrast, the most important sources of referral for Title III congregate participants are family, friends, neighbors, and participant self-referrals. For 70 percent of all Title III nutrition projects providing or arranging congregate meals, referrals from family and friends are the first or second most important referral source.

TABLE IV.28

NUTRITION PROJECT PARTICIPANT REFERRAL SOURCES

(Percentages)


Title III Congregate Meal Programs


Title III Home-Delivered Meal Program


Use Source

Rank Source

"1" or "2" in

Importance


Use Source

Rank Source

"1" or "2" in Importancea

Hospitals or Intermediate Care Facilities

76

10


92

45

Medical Doctors

81

18


92

30

Case Management Service Agencies

82

11


83

23

Other Community Agencies

88

15


86

20

Participant Self-Referral

97

38


95

16

Family or Friends

97

70


95

47

Other

44

15


31

7

Unweighted Sample Size

230

230


207

207

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

2. Participation in the USDA Commodities or Cash in Lieu of Commodities Program

Title III requires USDA to provide state agencies with either commodities or cash in lieu of commodities. States have latitude in whether they offer one or both of these options to nutrition projects. In some states, for example, nutrition projects have the option of receiving commodities or cash in lieu of commodities (or some combination of commodities or cash). In other states, SUAs have not established a direct commodities program available to the projects, and only the cash in lieu of commodities option is available. (Commodities are surplus food items sold by USDA at a discount.) Typical examples of commodities are frozen or chilled beef or poultry, cheese, pasta, rice, canned or frozen vegetables, flour, vegetable oil, and butter. Legislation has authorized a ceiling for reimbursements under the USDA commodity program, set at a certain monetary value per meal served. [ Title III agencies complete a monthly meal service report, on which the entitlement level is based. For fiscal year 1994, reimbursement was set at 60.6 cents per meal (U.S. General Accounting Office 1995).] In fiscal year 1994, USDA provided SUAs with about $146 million in cash reimbursements and a total of $7.3 million in commodities (U.S. General Accounting Office 1995). [ Of the $7.3 million in commodities, $1.2 million came from the USDA surplus removal and price support legislative authorities and was provided to agencies that requested at least 20 percent of their USDA reimbursements as commodities.]

Many observers believe that, for nutrition projects equipped to handle commodities, accepting them rather than cash in lieu of commodities is more cost-effective. Furthermore, additional commodities are available for state or local area agencies that take at least 20 percent of their program benefits as commodities. Congress requested that the evaluation examine how frequently the commodities option is used and reasons why it is not used.

SUA Level. Nearly two-thirds of SUAs currently elect to use the USDA cash-only option; one-third use a combination of cash and commodities (Table IV.29). In states using commodities, SUAs reported wide variation in the degree to which individual nutrition projects accept this option. In about one-third of the states in which commodities are available, one-fifth or fewer of the nutrition projects use USDA commodities. On the other hand, in 39 percent of the states in which commodities are available, more than 80 percent of the nutrition projects use them.

TABLE IV.29

USDA COMMODITY AVAILABILITY AND USE AT STATE LEVEL

(Percentages)

SUAs

States Elect to Use:


Commodities only

*

Cash in lieu only

63

Cash and commodities

33

None

4

Percentage of Nutrition Projects in State Using Commodities


Zero

67

1 to 20

11

21 to 40

4

41 to 60

4

61 to 80

2

81 to 100

13

Reasons SUAs Do Not Order Commoditiesa


Storage costs too high

51

Quantities too large to be practical

14

Transportation costs too high

37

Selections not broad enough

26

Use limits flexibility

11

Selections not appropriate for older peopleb

8

Use caterer/caterer can’t useb

8

Hard to planb

3

Qualityb

3

Pick cash because easierb

8

Other

34

State Encourages the Use of Commodities by Nutrition Projects

41

Sample Size

54

Source: Elderly Nutrition Program Evaluation, SUA survey.

a Tabulated for only those SUAs that do not elect to use USDA commodities (n = 36).

b Category was not an option on questionnaire. Frequencies are based on verbal responses to "other--specify" option and therefore may be underrepresentative.

* = Less than 0.5 percent.

For states that do not elect to receive USDA commodities, the most common reason mentioned is the high cost of storing commodities (51 percent). Other major reasons given by states for not choosing USDA commodities are transportation costs (37 percent), lack of variety in the commodities available (25 percent), and quantities are too large to be practical (14 percent). Some SUAs mentioned logistical problems with canceled orders, unexpected price changes on products, and the foods’ lack of appropriateness for older people, as other reasons they do not use commodities. [ These findings broadly support the observations made by the U.S. General Accounting Office (GAO) in its recent review of several USDA programs (U.S. General Accounting Office 1995) and by the AoA (U.S. Department of Health and Human Services, Administration on Aging 1993). The GAO report cited providers who were unhappy that commodities were not available from month to month, making meal planning difficult. Other complaints were that substitute commodities are often not appropriate for elderly people. The AoA report also listed reasons that nutrition programs do not use commodities: 31 percent reported the lack of variety, 17 percent mentioned storage and space costs, and 17 percent mentioned transportation costs. The primary reason for using commodities, cited by 18 percent of SUAs, is the availability of bonus items.]

Nutrition Project Level. Nutrition projects were also asked whether they use USDA commodities, USDA cash in lieu of commodities, both, or neither, as well as the reasons, if they choose not to use them. More than two-thirds of Title III nutrition projects use cash in lieu of commodities exclusively (Table IV.30). The reasons projects mentioned most commonly for not receiving commodities include lack of storage facilities (16 percent), incompatibility of commodities with the use of caterers and contractors (14 percent), and lack of variety (11 percent). Other reasons include restrictions on commodity use by higher levels of the ENP and inappropriateness of commodities for certain racial and ethnic groups. A few nutrition projects indicated either dissatisfaction with the quality of the commodities or a belief that it is more cost-effective to use cash rather than commodities.

TABLE IV.30

USDA COMMODITY USE BY NUTRITION PROJECTS

(Percentages)

Commodity Use

Title III Nutrition

Projects

USDA Option Chosen by Nutrition Project


USDA commodities only

2

USDA cash in lieu of commodities option only

70

Both USDA commodities and cash

11

None

17

Percentage of Allotment Received as Commoditiesa


1 to 10

*

11 to 20

9

21 to 30

9

31 to 50

5

51 to 99

62

100

16

Reasons for Not Getting USDA Commodities, for Projects that Receive Cash Onlyb


Quantities too large to be practical

5

Transportation cost too high

6

Lack of storage facilities/storage cost too high

16

Selections are not broad enough/lack of variety

11

Receipt limits flexibility

6

Not available in this state

11

Selections not appropriate for older people

6

Use caterer/caterer can’t usec

14

Selection not appropriate for racial and ethnic groupsc

5

AAAs set policyc

6

Hard to planc

3

Qualityc

3

Cash cheaper/easier

1

Don’t know

7

Other

31

Unweighted Sample Size

242

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

Note: One nutrition project was excluded from the analysis of largest, middle, and smallest thirds of projects because of missing data on project size (meals served).

a Tabulated only for those projects receiving commodities (either commodities only, or both commodities and cash).

b Tabulations only for those nutrition projects that do not receive USDA commodities.

c Category was not an option on questionnaire. Frequencies are based on verbal responses to "other--specify" option and therefore may be underrepresentative.

* = Less than 0.5 percent.

Just 13 percent of Title III nutrition projects use commodities (Table IV.30). Projects accepting some commodities were asked about the proportion of their USDA allotment that they accept as commodities. Of those accepting any commodities, the majority (78 percent) accept more than half of their allotment in commodities.