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Nutrition

Evaluations Report

IV. TITLE III PROGRAM ADMINISTRATION AND SERVICE DELIVERY
A. CHARACTERISTICS OF AGENCIES ADMINISTERING THE ENP

In Title III of the Elderly Nutrition Program (ENP), a multilayered administrative structure of public and private agencies delivers nutrition and social support services to meet the needs of older individuals. The typical Title III administrative hierarchy consists of six levels--the Administration on Aging (AoA) central office in Washington, DC, the U.S. Department of Health and Human Services (DHHS) regional office, the State Unit on Aging (SUA), the Area Agency on Aging (AAA), nutrition projects, and meal sites.

The Older Americans Act (OAA) has broad guidelines on the responsibilities of the various administrative layers. For example, the AoA central office is required to distribute monies to the states in conformance with legislated requirements and to ensure overall conformance with program requirements by reviewing state plans proposed by the SUAs. The SUAs, in turn, must designate planning and service areas and must develop rules for allocating monies among areas in their states. They also select and supervise the AAAs. The AAAs then make grants or contract awards to nutrition projects. However, within the framework of these guidelines, program operations often vary widely in different parts of the country and even in different parts of the same state.

As concern about large federal budget deficits continues to increase, all public programs, including the ENP, are under scrutiny to assess whether their operations are as efficient as possible. A number of research questions specified by Congress in the authorizing legislation for the current evaluation pertain to this area and are addressed in this chapter (as well as in Chapter V, which examines funding and cost issues). Furthermore, to assess information in previous chapters about ENP impacts on participants, it is important to understand the structure of the program and how it operates.

This chapter describes the ENP and its operations, on the basis of information obtained from telephone and in-person interviews with staff of the organizations in the aging network that administer and operatethe program. We begin this chapter by describing, in Section A, organizations that administer Title III nutrition services. Section B looks at the array of nutrition and supportive services provided to ENP participants. Section C documents the nutritional expertise of program staff at each organizational level. Sections D examines interrelationships among different layers of ENP administrative organizations in terms of the technical assistance and training provided and received and monitoring and assessment. Interactions between ENP and non-ENP agencies, such as other providers of home- and community-based long-term care and the U.S. Department of Agriculture (USDA), are examined in Section E. The quality of program services, including food safety and sanitation policies and procedures, is discussed in Section F. Policies and procedures used to target services to economically and socially disadvantaged groups of older persons are discussed in Section G. In Section H, we examine the prevalence of waiting lists at the project level.

A. CHARACTERISTICS OF AGENCIES ADMINISTERING THE ENP

Under Section 305 of the OAA, Title III of the ENP is typically administered at four different levels below the DHHS regional office level: (1) the SUA; (2) the AAA; (3) the nutrition project (sometimes referred to as the nutrition service provider); and (4) the individual meal preparation and/or delivery site. In some instances, these levels are collapsed, so that one organization performs the tasks of more than one level. For example, in 14 states and territories that are designated as single-state planning and service areas, there are no AAAs per se--the SUA functions as the AAA. In many planning and service areas, the AAA also functions as a direct provider of nutrition services; sometimes, it is the only service provider. Characteristics of each of these entities are described next. [ No interviews were conducted at the DHHS regional office level. However, some data in Section D address SUA officials ' perceptions of the training and technical assistance provided by the regional offices. ]

1. SUAs

States are required to assign responsibility for administering the Title III ENP to a separate agency that is responsible for general issues and programs related to older people. The SUA is the agency at the state level that performs this administrative function. There are 57 SUAs, 1 in each of the 50 states, the District of Columbia, and six territories (Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa, Palau, and Puerto Rico).

States have considerable discretion about how this agency is constituted and the limits of its overall scope. Consequently, considerable variation exists among states in the agency to which SUAs report. Approximately 60 percent of the SUAs are part of a larger agency. Approximately half (49 percent) of SUAs report to cabinet-level agencies, such as a state health and human services department, or another office that deals specifically with aging (Table IV.1). Thirty-seven percent report directly to the state governor’s office. Some of the others indicated reporting to a "Department of Administration."

The typical (median) SUA has nine full-time staff persons dedicated exclusively to ENP state-level activities. When paid part-time employees are included, the median number of full-time-equivalent (FTE) staff working on the ENP at the state level increases to 12. [ These staff include full-time or part-time SUA staff, as well as paid persons on loan from other agencies, consultants, and any other paid individuals who work at least some time on the ENP at the state level. ]

The typical (median) SUA oversees 11 AAAs, although this number varies considerably from state to state. The typical (median) SUA oversees programs providing approximately 5,800 congregate and 5,400 home-delivered meals daily. In the largest states, these numbers can exceed 20,000 meals daily. These numbers suggest that nearly 1 million meals are served nationally per day in congregate and home settings.

TABLE IV.1

SUA ORGANIZATIONAL AND SERVICE CHARACTERISTICS

(Percentages, Unless Stated Otherwise)

Characteristic

SUAs

State Agency SUA Reports to:a


Governor’s office

37

Human services

49

Other

14

Number of AAAs in State or Territory


Median

11.0

Mean

13.3

Percentage of SUAs that Perform Functions of AAAsa,b

25

Average Daily ENP Congregate Meals in Service Area


Median

5,794

Mean

9,232

Average Daily ENP Home-Delivered Meals in Service Area


Median

5,374

Mean

7,679

Percentage of Total Meals that Are Congregate


Median

57.5

Mean

55.1

Percentage of Total Meals that Are Home-Delivered


Median

42.0

Mean

44.9

Number of Full-Time Staff Devoted to Title III ENP


Median

9.0

Mean

15.5

Number of Paid Full-Time-Equivalent Staff Devoted to Title III ENP


Median

11.7

Mean

18.2

Sample Size

55

Source:Elderly Nutrition Program Evaluation, SUA survey.

a Based on AoA program data.

b Refers to single-state planning and service areas in which the SUA functions as the AAA.

2. AAAs

AAAs establish, coordinate, and make accessible a network of services older persons may need for independent living. Each AAA operates within a specific geographic area known as a planning and service area, designated by the SUA. There are currently 668 AAAs in the Title III program. In 14 states and territories designated as single-state planning and service areas, the SUA fulfills the AAA role.

The OAA requires that AAAs be public or private nonprofit organizations. In practice, the AAAs are somewhat more likely to be public organizations than private, nonprofit organizations (55 percent and 44 percent, respectively; see Table IV.2). About 27 percent of AAAs are county governments; nearly one-quarter are also organizations created by consortia of governments (including government councils and regional commissions).

The typical (median) AAA has three full-time staff dedicated exclusively to performing ENP AAA-level activities. Some AAAs operate without any full-time paid staff, 13 percent have only one full-time staff member, 40 percent have between 2 and 10 full-time staff, and a few agencies employ more than 20. AAAs make some use of part-time staff. When part-time employees are converted to full-time-equivalents (FTEs), the median number of FTE staff at the AAA-level increases to four.

To get a sense of the size of areas AAAs serve, respondents were asked to indicate how far away the furthest points in their service areas were from their main offices. Many AAAs serve very large areas. About 20 percent reported a furthest distance of more than 100 miles; the mean and median distances are 74 and 60 miles, respectively.

Forty-two percent of AAAs run one or more nutrition projects directly, with one-quarter of all AAAs reporting that they operate the only nutrition project in their planning and service area. About 700 congregate meals and 600 home-delivered meals are provided daily by nutrition providers in the service area administered by the typical AAA.

TABLE IV.18

NUMBER AND DUTIES OF REGISTERED DIETITIANS IN TITLE III ENP

(Percentages)

Characteristic

SUAs

AAAs

Nutrition Projects

Have Access to Staff with Nutrition Credentials

85

73

60

Registered Dietitians (RDs)




Number of RDs




0

31

39

59

1

51

50

31

2 or more

18

11

10

RDs in Positions Requiring RD

52

52

35

Duties of RD




Perform management or administrative duties

54

29

20

Provide technical assistance or training

69

60

37

Develop materials, procedures, or standards

63

54

33

Monitor or assess services

61

51

33

Provide services

--

--

36

Staff with Other Nutrition Credentials




Number of Staff with Other Credentials




0

60

64

59

1

31

23

18

2 or more

9

13

23

Types of Other Staff Credentialsa




Dietitians but not RDs

4

5

8

Nutritionists but not RDs

13

6

18

Certified dietary managers

*

5

21

Dietetic technicians

2

2

2

Graduates of four-year nutrition programs

7

9

5

Graduate home economists

15

8

17

Certificate or training in food handling, service, or sanitationb

2

6

15

Course work in nutrition or food serviceb

4

3

4

Graduate of other related four-year programb

2

1

1

Other

4

4

7

Staff in Positions Requiring Nutrition Credentials

15

15

15

Unweighted Sample Size

55

401

242

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

a Percentage may add to greater than percentage with staff having other credentials because of multiple answers.

b Category was not an option on questionnaire. Frequencies are based on verbal responses to "other--specify" option and therefore may not capture all staff who possess those qualifications.

* = Less than 0.5 percent.

3. Nutrition Projects

The nutrition project is the administrative agency responsible for providing nutrition and supportive services within a defined community. Most nutrition projects--about 62 percent--are private nonprofit organizations (Table IV.3). Most of the rest (35 percent) are public entities, such as county or municipal governments. Participating nutrition projects have extensive experience operating the ENP program. More than 75 percent have been involved with the program for more than 10 years; more than 90 percent have been providing Title III services for at least 6 years.

TABLE IV.3

NUTRITION PROJECT ORGANIZATIONAL AND SERVICE CHARACTERISTICS

(Percentages, Unless Stated Otherwise)

Characteristic

Title III Nutrition Projects

Type of Organization


Public

35

Private, nonprofit

62

Private, for-profit

2

Other

1

Number of Years in Program


Less than 3

2

3 to 5

6

6 to 10

15

More than 10

77

Mean

15.7

Median

18.0

Number of Congregate Meal Sites Administer


0

5

1

39

2 to 5

20

6 to 10

18

11 to 20

12

More than 20

6

Mean

5.7

Median

5.0

Percentage of Meals Eligible for ENP Funding


100

79

90 to 99

17

80 to 89

2

Less than 80

2

Percentage of Budget Used for:


Meals eligible for ENP funding

78

Nutrition services eligible for ENP funds

19

Non-ENP activities

3

Unweighted Sample Size

242

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

The typical (median) nutrition project administers four congregate sites and also arranges for or provides home-delivered meal services. The range of congregate sites that each project supervises varies considerably: almost 40 percent administer only 1 meal site, and about 6 percent administer more than 20 sites.

The bulk of nutrition projects’ budgets goes toward providing meals eligible for ENP funding. Almost four-fifths of nutrition projects serve ENP meals exclusively. In only 2 percent of nutrition projects do ENP meals represent less than 80 percent of the total number of meals provided. Nearly 80 percent of nutrition providers’ budgets goes toward ENP-eligible meals; virtually all the rest (19 percent) is spent on other nutrition services eligible for ENP funds.

4. Congregate Meal Sites

The congregate meal site is the focal point for provision of Title III meals and supportive services. Meal sites are located in a variety of different types of facilities and settings. Most commonly, meal sites are located in a community center or senior center. This type of location accounts for 46 percent of the Title III meal sites (Table IV.4). Churches and converted businesses are also relatively common locations for Title III congregate meal sites (both at 11 percent). In addition, a wide variety of other locations is used, including township halls, hospitals, and converted libraries.

TABLE IV.4

MEAL SITE ORGANIZATIONAL AND SERVICE CHARACTERISTICS

(Percentages, Unless Stated Otherwise)

Characteristic

Title III Congregate Meal Sites

Type of Building Site Is In


Church

11

School

5

Converted business (storefront)

11

Office building

2

Converted residence

2

Community center (including senior center)

46

Retirement housing unit

8

Other

16

Condition of Building


Well maintained, clean

83

Structurally sound, functional, but unattractive, dirty, or in need of paint

15

Needs minor repairs (for example, to broken windows, sagging screen doors)

1

Other

1

Surrounding Neighborhood


All residential

25

Mix of residential and business

53

All business

14

Rural, not many buildings nearby

7

Other

1

Types of Public Transportation Availablea


Bus

62

Subway or train

9

Dial-a-ride or taxi services

60

Other

12

None

24

Floor Level of Site


Street level

88

Other

12

Percentage of Sites in Which Stairs Must Be Used

13



If Stairs Needed to Get to Meal Site, Number


1

26

2

4

3 to 5

35

More than 5

35

If Stairs, Handrails Available?


Yes

69

No

31

If Stairs, Alternatives Available?


Ramps

36

Elevator

9

Escalator

*

No alternatives

55

Maximum Meal Seating Capacity


Mean

93

Median

80

Typical Daily Attendance


Mean

37

Median

29

Weeks of Operation


Mean

51.9

Median

52.0

Home-Delivered Meals Provided Through Site?


Yes

53

No

47

Number of Paid Full-Time Staff


0

61

1

21

2 to 5

15

More than 5

3

Mean

0.9

Median

0.0

Number of Paid Full-Time-Equivalent Staff


0

1

0.01 to 0.49

15

0.50 to 0.99

36

1.00 to 1.49

16

1.50 to 1.99

6

2.00 to 5.00

21

More than 5.00

5

Mean

1.6

Median

0.9

Number of Volunteers


0

1

1

3

2 to 5

38

More than 5

58

Mean

13.8

Median

7.0

Number of Full-Time-Equivalent Volunteers


0

1

0.01 to 0.49

51

0.50 to 0.99

24

1.00 to 1.49

5

1.50 to 1.99

9

2.00 to 5.00

7

More than 5.00

2

Mean

1.0

Median

0.5

Unweighted Sample Size

158

Source: Elderly Nutrition Program Evaluation, Meal Site survey, weighted tabulations.

aPercentages sum to greater than 100 percent because multiple responses were permitted.

* = Less than 0.5 percent.

The vast majority of sites--83 percent--were described by interviewers as clean and well maintained. Sixteen percent were described as functional but either unattractive, not well maintained, or in need of minor repair. Twenty-five percent of the Title III sites visited are in all-residential areas. About 53 and 14 percent of the Title III sites, respectively, are in areas that are either a mixture of businesses and residences, or all business. Seven percent are in areas with few, if any, buildings nearby. A substantial proportion of Title III sites--about 62 percent--have bus service available. Other types of public transportation, such as dial-a-ride services, were also offered at many sites (60 percent). Twenty-four percent of the sites, however, have no public transportation available. These nutrition projects need to provide transportation to and from sites if participants are not able to get to the building by other means (for example, by providing their own transportation or getting assistance from friends or family members). In many instances, sites provide this assistance to the meal participants. [ Transportation assistance is discussed in detail in Section B. ]

In 13 percent of congregate sites, participants must use stairs to reach the meal site. [ Note that stairs may sometimes be necessary, even when a site is at street level.] In most of the sites with stairs (65 percent), there are five or fewer stairs to negotiate. Handrails are available at 69 percent of these sites, but fewer than half (45 percent) have either a ramp or an elevator as an alternate means of access.

Title III congregate meal sites vary greatly in size. The median Title III site is quite large, with maximum seating capacity for between 76 and 100 people; a few (four percent) have capacities of more than 200. Median typical attendance, however, is smaller, at about 30 people. On the basis of interviewer ratings, most sites have plenty of space at the tables (88 percent) and space for participants to move around and maneuver walkers and wheelchairs (87 percent).

More than 90 percent of congregate sites operate 52 weeks a year; the other 8 percent are generally closed one week a year. Virtually all congregate meal sites have at least some paid staff, but most haveno full-time paid workers. Only three percent have more than five paid full-time workers. When the time of part-time paid workers is converted to FTEs, two-thirds of Title III sites have approximately one FTE. Another quarter have between two and five paid FTEs.

Most sites make extensive use of volunteers. Fifty-eight percent of the Title III sites reported using more than five volunteers. The vast majority of these volunteers work only part-time: 80 percent of sites have less than one FTE volunteer. The median number of FTE volunteers at Title III congregate sites is 0.5. The sites use volunteers for a wide array of tasks. Table IV.5 indicates that volunteers most commonly serve food, clean up, serve as cashiers or hosts at the meal site, and deliver meals.

TABLE IV.5

DUTIES ASSIGNED TO VOLUNTEERS AT CONGREGATE SITES

(Percentages)

Characteristics

Title III Congregate

Meal Sites

Sites Using Volunteers

99

Duties of Volunteers


Serve Food

91

Clean Up

90

Set Tables

72

Cashier

43

Provide Host Meal Site

37

Deliver Home-Delivered Meals

32

Receive and/or Store Food Products or Supplies

31

Prepare Food

22

Administrative Tasks

19

Prepare and Maintain Data Records (for Example, on Food Production, Meals Served, or Client Characteristics)

17

Transport Clients

17

Other

12

Menu Planning

4

Food Purchasing

3

Unweighted Sample Size

157

Source: Elderly Nutrition Program Evaluation, Meal Site survey, weighted tabulations.