Nutrition

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.