AMERICANS ACT NUTRITION PROGRAMS
STANDARDS AND GUIDELINES
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
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).
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)."
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."
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
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.
early period of experimentation and growth, State agencies on aging
and NSPs had access to a wealth of additional resources to help them meet
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
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.
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
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.
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.
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."
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.
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.
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.
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.
provision, but less directive, was included in the 1978 amendments
to the Older Americans Act but never acted upon.
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.
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.
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
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.