## EXECUTIVE SUMMARY: SERVING ELDERS AT RISK; The Older Americans Act Nutrition Programs - National Evaluation of the Elderly Nutrition Program, 1993-1995 

The aging of the U.S. population has heightened interest in designing
efficient and effective systems for delivering health and related
services to older people. Developing service networks to provide elderly
people with a continuum of home- and community-based long-term care has
become especially important, to allow them to avoid unnecessary and
costly institutionalization.

One very important component of any overall package of home- and
community-based services for elderly people is nutrition services.
Adequate nutrition is critical to health, functioning, and quality of
life for people of all ages. For elderly people, nutrition can be
especially important, because of their vulnerability to health problems
and physical and cognitive impairments. Key nutrition services include
nourishing meals, as well as nutrition screening, assessment, education,
and counseling, to ensure that older people achieve and maintain optimal
nutritional status.

This publication summarizes the results of a comprehensive evaluation of
the largest U.S. community nutrition program for older persons, the
Elderly Nutrition Program (ENP). The ENP, which serves the general
elderly population under Title III of its authorizing legislation and
Native Americans under Title VI, is administered by the U.S. Department
of Health and Human Services (DHHS), Administration on Aging (AoA). The
evaluation was conducted by Mathematica Policy Research, Inc., in
conjunction with the University of Minnesota.

FINDINGS IN BRIEF The following are key findings of the evaluation:

Program Outcomes

-   People who receive ENP meals have higher daily intakes of key
    nutrients than similar nonparticipants.

-   ENP meals provide approximately 40 to 50 percent of participants\'
    daily intakes of most nutrients.

-   Participants have more social contacts per month than similar
    nonparticipants.

-   Most participants are satisfied with the services the ENP provides.

Participant Characteristics

-   Between 80 and 90 percent of participants have incomes below 200
    percent of the DHHS poverty level, which is twice the rate for the
    overall elderly population in the United States.

-   More than twice as many Title III participants live alone, compared
    with the overall elderly population.

-   Approximately two-thirds of participants are either over- or
    underweight, placing them at increased risk for nutritional and
    health problems.

-   Title III home-delivered participants have more than twice as many
    physical impairments, compared with the overall elderly population.

Funding

-   ENP expenditures are highly leveraged by state, tribal, local, and
    other federal monies and services and are also augmented by
    donations from participants. Typically, \$1.00 of Title III funds
    spent on congregate services is supplemented by an additional \$1.70
    from other sources (to result in total program expenditures of
    \$2.70). The amount of leveraging is substantially higher for Title
    III home-delivered services and lower for Title VI.

-   The average cost of an ENP meal, including the value of donated
    labor and supplies, seems reasonable. For Title III, a congregate
    meal costs \$5.17, and a home-delivered one costs \$5.31. The
    comparable costs for Title VI are \$6.19 and \$7.18, respectively.

Program Operations

-   The ENP is closely linked to other parts of the nation\'s emerging
    home- and community-based long-term care system, particularly
    through cross-referrals and coordination of service delivery by many
    ENP agencies at all levels within the aging network.

-   The ENP provides a continuum of nutrition services, in addition to
    meals, to participants. This continuum includes nutrition screening,
    assessment, education, and counseling.

-   ENP meals supply well over 33 percent of the Recommended Dietary
    Allowances (RDAs) for key nutrients. The meals are also \"nutrient
    dense\"\--they provide high ratios of key nutrients to calories.

-   Forty-one percent of Title III ENP service providers have waiting
    lists for home-delivered meals, suggesting a significant unmet need
    for these meals.

BACKGROUND The ENP is authorized under the Older Americans Act (OAA) and
is administered by the AoA. The AoA gives state units on aging (SUAs)
Title III-C grants to help them provide daily meals and related
nutrition services in congregate (group) or home settings to people age
60 and older. The ENP targets its services to older people with the
greatest economic and social need. In fiscal year (FY) 1994, Title III-C
funding for the ENP was nearly \$470 million.1 During this year, 127
million meals were served to 2.3 million people at congregate sites, and
more than 113 million home-delivered meals were provided to 877,000
homebound elderly people.

Title VI established a grant program for tribal organizations to help
them deliver social and nutrition services to older American Indians,
Alaskan Natives, and Native Hawaiians. These services are comparable to
those provided under Title III. In 1994, 226 American Indian and Native
Hawaiian grantees received nearly \$17 million in Title VI funds for
nutrition and supportive services. These grantees served 1.3 million
meals to 41,000 congregate participants and 1.5 million meals to 47,500
home-delivered participants.

![](media/image1.png){width="6.25in" height="4.729166666666667in"}

Under Title III and Title VI, SUAs and Indian Tribal Organizations
(ITOs) receive grants for congregate nutrition services, home-delivered
nutrition services, and supportive services. The OAA also requires the
U.S. Department of Agriculture (USDA) to provide SUAs and ITOs with
commodities or cash in lieu of commodities, in amounts based on the
number of meals they serve annually.2

SUAs distribute Title III funds to Area Agencies on Aging (AAAs), which
administer the nutrition programs in their planning and service areas
(Figure 1). The AAAs award grants to and contract with nutrition
projects to provide nutrition and supportive services in their planning
areas. Many AAAs also provide nutrition services directly to
participants. In addition to receiving AoA and USDA funds, nutrition
projects get financial support from state and local government, donated
food and supplies, private donations, and voluntary contributions from
participants. Congregate meals are served at meal sites (such as senior
centers, religious facilities, schools, public or low-income housing, or
residential care facilities). Home-delivered meals are taken to
homebound clients, either from the congregate meal sites, affiliated
central kitchens, or nonaffiliated food service organizations.

Congregate and home-delivered nutrition projects must offer at least one
meal per day, five or more days per week (except in rural areas). On
average, each meal must provide a minimum of one-third of the daily RDAs
established by the Food and Nutrition Board of the National Academy of
Sciences National Research Council. The meals must also comply with the
Dietary Guidelines for Americans, published by the Secretaries of DHHS
and USDA.

Under Title VI, the federal government awards funds directly to ITOs
from federally recognized tribes and to public or nonprofit private
organizations representing Native Hawaiians. AoA and USDA funding for
Title VI is supplemented by Title III funds, participant donations,
tribal funds, and state and local resources. Funds received by Title VI
grantees are dispensed to senior centers and other programs that serve
American Indian elderly people. The Title VI program provides nutrition
and supportive services that are similar to those provided by the Title
III program. Meals served under Title VI must comply with the standards
established for Title III; however, the minimum age for program
eligibility may be lower.

STUDY\'S PURPOSE AND APPROACH America will face critical challenges in
the coming decades as it attempts to provide long-term care services to
the nation\'s elderly people. As the large group of individuals born
after World War II ages, a much higher proportion of Americans will be
elderly and will require more health services and long-term care. At the
same time, however, concern about the federal deficit has constricted
the resources available to meet these needs.

In this context, public policy programs must demonstrate their
effectiveness in accomplishing their objectives efficiently. It is
essential to examine whether these programs produce the intended impacts
and whether their services are directed to those who need them most. It
is also important to look at the efficiency of program operations and
whether funding streams are adequate.

In light of these issues, the U.S. Congress authorized DHHS to conduct
the first full evaluation of the ENP in more than a decade. A
comprehensive evaluation, covering all aspects of ENP operations and
funding, was mandated in the ENP\'s authorizing legislation. The
legislation specified 19 requirements for the evaluation, discussed in
detail in the full report. These requirements were incorporated into the
following objectives for the evaluation:

-   To evaluate the ENP\'s effects on participants\' nutrition and
    socialization, compared with similar nonparticipants

-   To evaluate who is using the ENP and how effectively the program
    serves targeted groups most in need of its services

-   To assess how efficiently and effectively the ENP is administered
    and delivers services

-   To clarify ENP funding sources and allocation of funds among its
    components

A comprehensive research design, involving both extensive data
collection and multiple lines of analysis, was necessary to meet these
objectives. To collect the required data, Mathematica® interviewed ENP
participants and staff from all levels of the program structure,
including SUAs, AAAs, ITOs, nutrition projects, and congregate meal
sites. For the Title III program, Mathematica also interviewed a
comparison group of nonparticipants, chosen to be as similar to the
participant group as possible.3

Study Limitations This study is the most comprehensive evaluation of the
ENP in the past 15 years. It also provides important information about
participants and program impacts. Interpretations of the results
summarized here, however, must be made in light of the study\'s
limitations. Four key limitations are highlighted next.

Lack of Random Assignment. The strongest evaluation design for measuring
the effects of the ENP on participants would have randomly assigned
potential participants to the program or to a control group that did not
receive program services, for a specific assessment of program impacts
over time. A prospective randomized design was not possible, however.
Instead, Mathematica selected a sample of nonparticipants in the same
locations as participants, matching them in terms of key
characteristics. Without random assignment, underlying differences
between the participant and nonparticipant groups might confound the
comparisons made in the impact analyses. Mathematica minimized this
possibility, however, by matching the comparison group to the
participant group as closely as possible, and by using statistical
techniques to control for observable differences.

Sampling Error. With the exception of the data collection from SUAs, all
of the surveys in this study were based on samples of agencies or
respondents. As a result, the numerical estimates reported here are
subject to possible error caused by random statistical variation. In
general, however, the sample sizes were large enough so that sampling
error, while present, is probably not large enough to affect the
conclusions.

Potential Measurement Error in Meal Cost Estimates. Many nutrition
projects in the ENP do not keep detailed-enough cost records to provide
consistent cost information across projects. Accordingly, Mathematica
\"built up\" cost estimates on the basis of detailed information from
the projects about local operations, staff wage rates, and other
factors. This process may have introduced some measurement error into
the detailed cost estimates, but Mathematica is confident that the
overall order of magnitude of the cost estimates is correct.

Difficulties in Allocating Funding by Source. The agency surveys asked
respondents to provide information on total funding and funding by
source, separately for congregate meals, home-delivered meals, and
supportive services. Because meals and supportive services are closely
intertwined in many projects, it was often not possible to link services
with specific funding sources. As a result, much of the analysis of
program funding relied on aggregate program data.

These limitations should be kept in mind in assessments of the study\'s
overall findings. Despite these limitations, however, the basic
conclusions drawn here are strongly supported by the information
collected in the study. Next, we provide more detailed data on each
evaluation objective.

PROGRAM OUTCOMES The evidence suggests that the ENP has substantial
positive impacts on participants. In particular, Title III participants
have higher daily intakes of key nutrients, as well as more social
contacts per month, than the comparison group. It is likely that these
differences are at least partially caused by the ENP.

24-Hour Nutrient Intakes To explore ENP impacts on daily nutrient
intakes, Mathematica interviewed a comparison group of older people who
were similar to Title III participants but did not participate in the
ENP. Daily nutrient intakes as a percentage of the RDAs are higher for
both Title III congregate and home-delivered participants who receive
program meals, relative to the comparison group (Figure 2). These
results suggest that the program is increasing participants\' dietary
intakes on days when they receive program meals. Both congregate and
home-delivered participants have significantly higher intakes of the
nutrients with the lowest average intake levels (such as food energy
\[calories\], zinc, calcium, and vitamin B6). Similar results were also
obtained for most other nutrients (not shown in figure). Most of the
observed differences for participants are statistically significant.
There are no significant differences between participants\' and
nonparticipants\' intakes of sodium and cholesterol, or in their intakes
of carbohydrate, protein, total fat, and saturated fat as a percentage
of food energy (calories).

![](media/image2.png){width="6.25in" height="4.729166666666667in"}

ENP Nutrient Intakes Versus Overall Nutrient Intakes The ENP plays a
very important role in participants\' overall dietary intakes. Nearly
all home-delivered participants and one-half of congregate participants
receive five or more program meals a week. These meals supply a large
part of their total nutrient needs. More than a third of home-delivered
participants save part of the program meal to eat as a second meal, part
of a second meal, or a snack. Twelve percent of congregate participants
take either an additional full meal or a snack home for later
consumption.

For almost all of the nutrients studied, congregate meals supply well
over a third of participants\' daily intakes. In fact, for most
nutrients, the contribution to daily intakes is in the range of 40 to 50
percent (Figure 3). A similar pattern exists for home-delivered meals,
although the contributions tend to be a few percentage points lower for
this component. These results, which apply to both Title III and Title
VI, indicate that the ENP plays an important role in participants\'
overall nutrition. Furthermore, the similarity in Title III and Title VI
contributions to dietary intakes suggests that the earlier findings
based on the use of a Title III comparison group can be generalized to
Title VI as well.

![](media/image3.png){width="6.25in" height="4.729166666666667in"}

Table 1: Nutrients in ENP Meals, as Served (As a Percentage of the Male
RDAs)

  -------------------- ------------ ---------------- -- ------------ ----------------
                       Title III                        Title VI     

                       Congregate   Home-Delivered      Congregate   Home-Delivered

  Food Energy          36           37                  37           33
  (Calories)                                                         

  Vitamin B6           38           44                  37           40

  Calcium              56           58                  50           47

  Zinc                 33           33                  33           28
  -------------------- ------------ ---------------- -- ------------ ----------------

NOTE: Program meals are required to supply 33 percent of the RDAs.

Nutrient Content of ENP Meals The average ENP meal meets the program\'s
requirement to provide at least one-third of the relevant RDAs (Table
1). Under both Title III and Title VI, the average meal provides more
than 50 percent of the adult male RDAs for many nutrients. Basing the
calculations on the RDAs for females (not shown in table) only
reinforces this comparison, because the RDAs for females are lower for
many nutrients. Table 1 also shows that ENP meals are relatively
\"nutrient dense,\" providing relatively large amounts of nutrients per
kilocalorie of food energy.

Under both Title III and Title VI, the estimated fat content as a
percentage of food energy is 36 percent for congregate meals and 35
percent for home-delivered meals, in excess of the 30 percent
recommended in the Dietary Guidelines for Americans (not shown in
table). Furthermore, when participants\' overall diets from program and
nonprogram sources of food are considered, their intakes of
fat\--especially those of Title III congregate and home-delivered
participants\--are closer to the Dietary Guidelines recommendations. For
example, the typical Title III participant consumes 32 percent of his or
her daily calories as fat (not shown). There is some controversy in the
scientific community about appropriate fat intakes for the elderly
population. Some experts view the fat standards for older persons as
overly stringent, particularly as they apply to the very old. Reducing
total fat and saturated fat, unless carefully managed, may compromise
the overall intake of food energy (calories) for older persons.

Social Contacts On average, both congregate and home-delivered
participants have about 14 more social contacts per month than the
comparison group (Table 2). This represents more than a 16 percent
increase in the number of social contacts per month. It also suggests
that the program increases socialization opportunities for participants.

It is important to note that direct program contacts\--either attendance
at a meal site or receipt of a meal delivery\--are included in the
estimates of contacts for participants. For congregate participants,
this inclusion is clearly appropriate, because these contacts usually
last for an hour or more and involve considerable social interaction.
The home-delivery contacts are usually much shorter, but about 25
percent of participants report that the ENP delivery person usually
spends at least some time in conversation with them (not shown in
table). Whether or not there is extended conversation, the majority of
home-delivered participants report that the contact with the delivery
person is important to them socially.

Table 2: Mean Number of Monthly Social Contacts for Participants and
Eligible Nonparticipants, Controlling for Other Characteristics

  -------------------- ---------------------- ---------------------------
                       Title III              Title III Home-Delivered
                       CongregateProgram      Program

  Participants         96                     98.6

  Matched              82.5                   83.3
  Nonparticipants                             

  Percentage           16.3\*\*               18.4\*\*
  Difference                                  
  -------------------- ---------------------- ---------------------------

\*\*Difference between participants and nonparticipants is statistically
significant at the .05 level, one-tailed test.

Satisfaction with Services Sixty-six percent of Title III congregate
participants and 65 percent of Title III home-delivered participants
describe themselves as \"very satisfied\" with how the food tastes
(Figure 4). The comparable figures for Title VI are 65 percent and 57
percent. For other questions on the food served, the numbers of \"very
satisfied\" tend to be 60 percent or more. Most of the respondents who
did not choose \"very satisfied\" (the highest level on the four-point
scale) selected the next-highest level, indicating they were \"somewhat
satisfied.\"

![](media/image4.png){width="6.25in" height="4.729166666666667in"}

When asked what they like most about the program, 77 percent of Title
III congregate participants and 70 percent of the Title VI counterparts
mentioned the other participants; 58 and 69 percent, respectively,
mentioned the meals; and 30 and 23 percent mentioned supportive
services. Seventy percent of Title III congregate participants and 61
percent of Title VI congregate participants take part in recreation
activities provided through the nutrition program. Fifty percent or more
of those participating in recreational activities at the meal site
report that these activities are either the only source or a major
source of their social activity. These responses suggest that
participants are generally satisfied with the meals and that the
socialization aspect of the program is also important to them.

PROGRAM PARTICIPANTS In principle, Title III is available to everyone
age 60 and older, but its authorizing legislation requires special
efforts to target the program to populations who particularly need ENP
services. The evidence from the evaluation shows that the program has
achieved considerable success in accomplishing this \"targeting\"
objective.

The ENP serves highly vulnerable people with characteristics that tend
to put them at increased health and nutritional risk. ENP participants
tend to be older, poorer, more likely to be members of racial or ethnic
minorities, and more likely to live alone, compared with the overall
population in the United States age 60 and older.4 Participants are also
more likely to be in poor health, to have greater difficulty performing
everyday tasks, and to have relatively high nutritional risk. These and
related client characteristics are examined next.

Demographic Characteristics For Title III, the average congregate meal
participant is 76 years old, and the average home-delivered participant
is 78 (Figure 5). By contrast, the average age in the overall U.S.
population age 60 and older is approximately 72. This pattern suggests
that the program is directing its services to people who, at least in
terms of age, are most likely to need them.

![](media/image5.png){width="6.25in" height="4.729166666666667in"}

The average ages of Title VI participants\--68 for congregate
participants and 71 for home-delivered ones\--are considerably lower
than those for Title III. In part, this reflects the fact that the
minimum age for eligibility in Title III is 60, but the minimum age for
eligibility in Title VI is established by ITOs and may be lower than age
60. In our survey, Title III participants ranged in age from 31 to 101;
the range for Title VI was 23 to 103.5

ENP participants have significant economic and/or social needs. About
one-third of Title III congregate participants and one-half of Title III
home-delivered participants have incomes at or below the DHHS poverty
threshold. More than one-half of Title VI meal participants have incomes
at or below this level. The comparable figure for the overall population
age 60 and older is 15 percent. Most of the rest are \"near poor,\" with
incomes between 100 and 200 percent of the poverty level (not shown in
figure). Between 80 and 90 percent of all participants have incomes
below 200 percent of the DHHS povertyy threshold, compared with 38
percent of the overall elderly population.. Non-Hispanic African
Americans constitute approximately 12 percent of Title III congregate
participants and 18 percent of home-delivered ones. Elderly people of
Hispanic origin make up, respectively, another 12 percent and five
percent of participants in the two parts of the Title III program.
Overall, racial and ethnic minorities constitute 27 percent of
congregate and 25 percent of home-delivered participants. Almost all
Title VI participants are members of minority groups, compared with 14
percent of the overall population age 60 and older.6

Both the congregate and home-delivered programs successfully target
subgroups of poor and minority elderly people. Furthermore, nearly four
times as many Title III participants and nine times as many Title VI
participants are low-income minorities, compared with the overall
population age 60 and older. These groups represent a substantially
larger proportion of participants than they do of the overall elderly
population.

More than twice as many Title III participants live alone, compared with
the overall elderly population (60 percent versus 25 percent).
Substantially fewer Title VI participants live alone (about 29 percent).
Nearly all Title VI participants, 28 percent of Title III congregate
participants, and 16 percent of Title III home-delivered participants
live in rural areas, compared with 25 percent of the overall elderly
population.

Health Problems and Functional Impairments Both Title III and Title VI
participants have significant numbers of health problems and functional
impairments that might place them at nutritional risk (Table 3). In both
parts of the ENP, participants tend to have between two and three
diagnosed chronic health conditions. In Title III, 26 percent of
congregate participants and 43 percent of home-delivered participants
had a hospital or nursing home stay in the year before the survey; a
similar pattern was observed in Title VI. Among home-delivered
participants, 63 percent of Title III participants and 45 percent of
Title VI ones rated their health as either poor or only fair. Many
participants reported health conditions such as heart disease, diabetes,
anemia, and osteoporosis for which nutrition intervention is either a
primary or a supportive form of treatment.

Table 3: Health and Functional Status of Participants (Percentages,
Unless Otherwise Noted)

  ------------------------------- ------------ ----------- -- ------------ -----------
                                  Title III                   Title VI     

                                  Congregate   Home-          Congregate   Home-
                                               Delivered                   Delivered

  Average Number of Diagnosed     2.4          3              2.8          2.9
  Chronic Health Conditions                                                

  Hospital/Nursing Home Stay in   26           43             30           37
  Previous Year                                                            

  Weight Outside of Healthy Range 61           64             65           69

  Difficulty Doing One or More    23           77             23           44
  Everyday Tasks                                                           

  Unable to or Have Much          8            41             8            26
  Difficulty Preparing Meals                                               

  Moderate to High Nutritional    64           88             80           78
  Risk                                                                     

  Instances of Food Insecurity in 10           16             17           15
  Past Month                                                               
  ------------------------------- ------------ ----------- -- ------------ -----------

There is also evidence that many participants are at nutritional risk.
Only about one-third have weight levels in relation to their height that
were within accepted normal ranges. Between 18 and 32 percent gained or
lost 10 pounds without wanting to during the six months before the
survey. Under criteria developed by the Nutritional Screening
Initiative, 64 percent to 90 percent of participants have
characteristics associated with moderate to high nutritional risk.

Under Title III, about one-quarter of congregate participants and more
than three-quarters of home-delivered participants have trouble doing
one or more everyday tasks. A similar pattern exists for Title VI
participants, although the proportion of Title VI home-delivered
participants with impairments is somewhat lower. Title III
home-delivered participants have an average of 3.7 functional
impairments; their Title VI counterparts have an average of 2.4.
Sixty-four percent of Title III home-delivered participants have
difficulty shopping for food; 41 percent are unable to prepare meals.
Overall, ENP participants, especially those served by the home-delivered
program, are more functionally impaired than the overall elderly
population.

Length of Time in Program For congregate meals, 45 percent of Title III
participants and 42 percent of Title VI participants have been in the
ENP for more than five years. Only about 10 percent of home-delivered
participants have received home-delivered meals for this long. There is
a moderate amount of fluidity between the two components of the ENP\--9
percent of Title III and 19 percent of Title VI congregate participants
have received home-delivered meals in the past. Nineteen percent of
Title III and 24 percent of Title IV home-delivered participants have
received congregate meals. Most current home-delivered participants,
however, have not participated in the congregate meals program in the
past. They represent a new pool of participants and have not aged in
place at the congregate sites.

PROGRAM CHARACTERISTICS All ENP congregate programs serve lunch. In
addition, about four percent of Title III congregate programs and two
percent of Title VI congregate programs serve breakfast. Most congregate
sites operate only on weekdays; however, about four percent of Title III
sites and one percent of Title VI sites also serve weekend meals. Most
of the projects that provide home-delivered meals deliver at least five
meals per week.7 A delivery usually includes only a single
meal\--typically a hot lunchbut some deliveries include more than one
meal at a time.

For Title III, about 49 percent of congregate sites make \"modified\"
meals available, such as those that are low in fat, sodium, or calories,
whereas 63 percent of home-delivered providers offer these types of
meals. The comparable numbers for Title VI are somewhat higher, at 67
percent and 76 percent, respectively. Most nutrition programs also
provide other meals, such as holiday or ethnic meals to meet
participants\' special needs. Some offer weekend home-delivered meals or
meals more than once a day; some provide support for food pantries.

There is wide variation within the Title III home-delivered program in
whether meals are prepared at a central kitchen, prepared on site, or
bought from a contractor. The most typical approach involves project
staff preparing food at congregate sites (43 percent). More than a third
buy meals from private contractors, however. Most Title VI programs (96
percent) prepare home-delivered meals at congregate sites. Meals at
congregate sites are usually served either cafeteria style or restaurant
style, with preportioned meals brought to participants at tables.

Other Nutrition Services Title III nutrition projects provide a variety
of nutrition-related services, in addition to meals. These include
nutrition education (about 87 percent of projects), 8 nutrition
screening (about 55 percent), and nutrition counseling (about 50
percent) (see Figure 6). Although providing other nutrition services in
addition to meals is somewhat less common for Title VI projects, more
than half report providing nutrition education. Between one-quarter and
one-third offer each of the other nutrition-related services discussed
here.

Sanitary Standards Food safety and sanitation procedures are an
important part of a nutrition program\'s overall quality. Seventy-six
percent of the states require that all ENP sites be inspected. Most of
the rest require inspection of food production sites but not necessarily
eating sites.

Eighty-six percent of Title III and 93 percent of Title VI facilities
report that their sites were inspected by the local health department
during the past year. Forty-four percent of Title III facilities had one
or more deficiencies during the last three inspections; however, almost
all of them (93 percent of those with deficiencies) had taken corrective
action. For Title VI, the rate at which deficiencies were found was
somewhat higher (56 percent), and the correction rate was slightly lower
(68 percent of those with deficiencies).

Of course, the major outcome of interest for safe food handling is
whether people become sick because of the food. Reported instances of
such illness do occur but are rare. In the more than 400 AAAs
surveyed\--which represent more than half of the AAAs in the
country\--only six incidents of illness associated with ENP food
occurred in the past three years. AAAs reported that 175 older persons
became ill in the past three years from these six incidents. None of the
115 ITOs surveyed\--which represent more than half the ITOs in the
country\--reported any incidents of illness in the previous three years.
It should be noted, however, that the actual incidence of food-borne
illness is believed to be considerably higher than the reported
incidence throughout the food service industry. Thus, the actual
incidence of food-borne illness associated with the ENP is probably
greater than that reported here, but not more than one percent of
participants get sick from program meals.9

UNMET NEEDS\
Home-Delivered Meals

Overall, the size of the ENP program in terms of meals served annually
has increased steadily since 1980, rising from 168 million to 240
million meals. This overall increase masks substantial differences in
the growth of program components, however. Although relatively steady
for much of the period, the overall provision of congregate meals
declined somewhat between 1980 and 1994 (the program served 132 million
meals in FY 1980 and 127 million in FY 1994). The home-delivered
program, on the other hand, grew rapidly during this period, tripling in
size, from 36 million to 113 million meals. In addition to reflecting
increasing need for home-delivered meals, this pattern could also
reflect available funding. It is possible that more congregate meals
would have been served had projects received more funding.

Program operators expect these patterns to continue. In response to a
question about expected program changes, most SUAs and AAAs, as well as
38 percent of nutrition projects, expected further increases in the need
for home-delivered meals. Furthermore, even this very rapid increase in
home-delivered meals does not appear to have kept up with the need for
them, as discussed in the next subsection.

Waiting Lists The number of older Americans, particularly the
functionally impaired, has been steadily increasing while funding for
OAA programs has generally remained flat. Sources such as the Wall
Street Journal (November 8, 1994) have reported ENP waiting lists in
various parts of the country, suggesting a relatively large degree of
unmet need for nutrition assistance among elderly people, especially
those who are severely impaired or homebound. The evaluation data
indicate considerable unmet need for home-delivered ENP meals.

Many of the nutrition projects that arrange or provide home-delivered
meals (41 percent) report having a waiting list for potential
participants (Table 4). For projects that maintain waiting lists, the
mean number of people on the lists is 85. It is important to note,
however, that the mean is heavily influenced by a few very large
projects with long waiting lists. Yet, even the median is 35 (not
shown), which is about 30 percent of the average project\'s number of
home-delivered participants served daily. Nutrition projects that
maintain waiting lists report that the mean length of time on the lists
is between two and three months. (Again, the median is lower.)

Waiting lists are much less common for congregate meal programs. Nine
percent of the nutrition projects arranging or providing congregate
meals report having waiting lists. One-fifth of Title III nutrition
projects, however, reported that they currently have a waiting list for
potential participants for other (nonmeal) nutrition and supportive
services, with an average time on the list of two months.

Table 4: Waiting Lists for Participation in Title III Programs, as
Reported by Nutrition Projects

  ---------------------------------- ----------------- --------------------- ----------
                                     CongregateMeals   Home-DeliveredMeals   Other
                                                                             Services

  Maintain Waiting List (Percentage) 9                 41                    22

  If Maintain Waiting List, Mean     52                85                    \--
  Number on Waiting List                                                     

  If Maintain Waiting List, Mean     2.1               2.6                   2.2
  Length of Time on List(Months)                                             
  ---------------------------------- ----------------- --------------------- ----------

Overall, these data, together with the earlier information on trends in
ENP meals served, suggest considerable unmet need for home-delivered ENP
meals. Furthermore, the findings summarized here probably understate the
degree of unmet need for home-delivered as well as congregate meals. It
is probable that many nutrition programs with unmet need for services do
not maintain waiting lists.

Most ENP participants report having enough food to eat, but 10 to 17
percent reported one or more recent instances of food insecurity, such
as having no money to buy food or having to choose between buying food
and buying medications during the previous month. In Title III, 10
percent of congregate participants and 16 percent of home-delivered ones
mentioned one or more instances of food insecurity during the past
month. The comparable numbers for Title VI are 17 percent and 15
percent. Although these percentages appear relatively modest, they mean
that, within the 30 days preceding the interview, approximately 240,000
congregate participants and 130,000 home-delivered participants had
experienced food insecurity.

LINKS TO OTHER HOME-AND COMMUNITY-BASED CARE The legislation authorizing
the evaluation focused on the need to examine the ENP\'s degree of
integration with other parts of the home and community-based long-term
care system. One important aspect of this issue\--participants\'
characteristics\--has already been discussed. As noted, most ENP
participants have characteristics, such as age, difficulty doing
everyday tasks, and poverty status, that increase the likelihood that
they will need home- and community-based long-term care services. Here,
we examine a number of other linkages:

-   ENP participants\' use of home- and community-based long-term care
    services

-   Referral sources for the ENP

-   Direct provision by ENP providers of home- and community-based
    long-term care

-   ENP agencies\' coordination with other providers of home- and
    community-based long-term care

Use of Other Services The use of non-nutrition support services by ENP
participants shows the degree to which the ENP functions as part of the
broader home- and community-based long-term care network. Twenty-nine
percent of Title III home-delivered participants also receive personal
care services, either from the ENP provider or another public or private
source (Table 5). Thirty-five percent receive homemaker services and 14
percent receive home health aid services from providers who are not
their families or neighbors. When families or neighbors are counted, 66
percent of Title III and 56 percent of Title VI home-delivered
participants receive homemaker services; 39 percent of Title III and 18
percent of Title VI home-delivered participants receive personal care
services, designed to maintain frail individuals in their home and.
communities. As might be expected, congregate participants are
significantly less likely than their home-delivered counterparts to use
long-term care services. Compared with Title VI home-delivered
participants, a larger percentage of Title III home-delivered
participants use home- and community-based long-term care services and
receive a greater percentage of the services from private or public
agencies. This pattern may reflect greater impairment or greater
availability of services, or some combination of the two.

Referrals to the ENP Forty-five percent of Title III home-delivered
participants and 43 percent of their Title VI counterparts first heard
about the ENP through a hospital or community-based organization (Table
6). Most of the rest heard about the program through family or friends.
The corresponding numbers for congregate participants are considerably
lower, at 12 percent and 16 percent, respectively. This pattern suggests
that, as might be expected, agencies attempting to assemble an
integrated package of long-term care services for their clients
frequently include ENP home-delivered meals. Correspondingly, nutrition
projects report that hospitals or intermediate-care facilities are the
first or second most common source of referrals for participants in the
home-delivered program (not shown).

Table 5: Use of Home- and Community-Based Long-Term Care by Participants
(Percentages)

  ------------ --------------- ------------- -- ---------------- -------------
               Congregate                       Home-Delivered   
               Participants                     Participants     

               From Private or From All         From Private or  From All
               Public Agency   Sources,         Public Agency    Sources,
               Providers       Including        Providers        Including
                               Family                            Family

  Title III                                                      

  Personal     2               6                29               39
  Care                                                           
  Services                                                       

  Homemaker    1               23               35               66
  Services                                                       

  Home Health  2               2                14               16
  Aide                                                           
  Services                                                       

  Adult Day    2               2                2                2
  Care                                                           
  Services                                                       

  Title VI                                                       

  Personal     2               5                6                18
  Care                                                           
  Services                                                       

  Homemaker    7               30               8                56
  Services                                                       

  Home Health  7               8                8                10
  Aide                                                           
  Services                                                       

  Adult Day    1               1                1                1
  Care                                                           
  Services                                                       
  ------------ --------------- ------------- -- ---------------- -------------

Information and Referral Most nutrition projects do not directly provide
more-intensive long-term care services, such as personal care,
homemaker, or home health aide services. These services are slightly
more likely to be provided to home-delivered participants, but the
percentages of projects providing these services are low, ranging from
about 4 to 14 percent, with most below 10 percent.

Even though the majority of nutrition projects do not provide major
long-term care services directly, they function as part of the larger
network of community systems to address the comprehensive long-term care
needs of elderly people. Table 7 on the next page shows that
approximately 85 percent of both Title III and Title VI projects offer
information and referral services to participants.

Table 6: Participants\' Referral to the Program (Percentages)

  -------------------------------- ------------ ---------------- -- ------------ ----------------
                                   Title III                        Title VI     

                                   Congregate   Home-Delivered      Congregate   Home-Delivered

  How Long Ago Began Participating                                               

  Less than 6 months               9            17                  10           15

  6 to 11 months                   7            18                  4            4

  1 to 5 years                     40           54                  44           58

  6 to 10 years                    25           9                   23           13

  More than 10 years ago           20           2                   19           9

  How First Heard About the                                                      
  Program                                                                        

  Family member or friend          68           44                  60           42

  Community-based organization or  12           45                  16           43
  hospital                                                                       

  Newspaper, radio, or television  5            2                   2            1

  Posters or announcement in mail  1            1                   1            5

  Announcement in church or club   6            1                   4            ?

  Other method                     8            7                   18           9

  On Waiting List Before Receiving 2            13                  \*           2
  Meals                                                                          

  Received Other Long-Term Care    5            22                  2            13
  Services Before Receiving Mealsa                                               
  -------------------------------- ------------ ---------------- -- ------------ ----------------

a The most commonly mentioned home- and community-based long-term care
services were home health, personal care, and homemaker services.
Congregate participants most commonly mentioned transportation,
homemaker, and personal care services.

\* = Less than 0.5 percent.

Table 7: Nutrition Projects Offering Various Types of Non-Nutrition
Services (Percentages)

  --------------------------------- ----------------- --------------------
  Service Provided                  Congregate        Home-Delivered
                                    Participants      Participants

  Title III                                           

  Information and Referral          85                84

  Recreation and Social Activities  69                NA

  Transportation to and from Meal   68                NA
  Site                                                

  Other Assisted and Nonassisted    57                58
  Transportation                                      

  Other Counseling                  53                55

  Homemaker Services                12                14

  Personal Care Service             4                 5

  Home Health Aide Services         5                 6

  Title VI                                            

  Information and Referral          89                86

  Recreation and Social Activities  75                NA

  Transportation to and from Meal   83                NA
  Site                                                

  Other Assisted and Nonassisted    77                81
  Transportation                                      

  Other Counseling                  49                52

  Homemaker Services                7                 7

  Personal Care Service             7                 7

  Home Health Aide Services         4                 4
  --------------------------------- ----------------- --------------------

NA = Not applicable.

Recreational and social activities are provided by about two-thirds of
both Title III and Title VI projects serving congregate meals. The
majority of III and Title VI projects also offer transportation services
other than to and from the meal site.

Coordination of Services To explore relationships with other components
of the long-term care system, the survey included an open-ended question
about ENP agencies\' efforts to coordinate with providers of other
long-term care. The responses showed a broad range of interconnections:

-   SUAs are involved in administering, coordinating, and funding
    ongoing home- and community-based long-term care services. In many
    states, SUAs are making direct efforts to develop policies to
    coordinate the ENP with other services.

-   ITOs frequently integrate the ENP with their broader planning and
    delivery of home- and community-based long-term care services.

-   Most AAAs are involved in directly providing one or more long-term
    care services. These services involve managing participants\'
    long-term care needs or facilitating access to care (through case
    management and information and referral). Some AAAs and ITOs also
    indicate that they are major direct providers of long-term care
    services as well.

-   Most nutrition projects carry out specific activities in which they
    either directly provide their clients with needed home- and
    community-based long-term care or connect them with other providers
    of these services.

ENP and the Broader System To interpret the information discussed here,
it is useful to place it in the broader context of long-term care in the
United States. The long-term care system can be viewed as the entire set
of providers\--including family members, individuals, agencies, and
institutions\--that deliver a continuum of health and related supportive
services, including nutrition services, to older people, depending on
their needs. For relatively healthy older people, these services focus
on prevention or optimal management of health problems and their
complications. These services may also address factors that compromise
health or independence and prevent acute or long-term
institutionalization. For less healthy older people who are frail but
still living in their communities, the focus is on providing services,
such as an array of in-home health care and homemaker services, to
assist them in living independently as long as possible and in
preventing premature long-term institutionalization. Finally, for older
people who can no longer function independently in community settings,
the challenge of the long-term care system is to provide
institution-based care that preserves individual dignity, quality of
life, and remaining independence.

The two major components of the ENP\--congregate and home-delivered
meals\--serve participants who have different needs for long-term care
services. Most congregate participants fall at the end of the continuum
that focuses on providing long-term preventive services. Only 8 percent
of these individuals have difficulty or need assistance preparing meals
for themselves, and only 23 percent have trouble doing everyday tasks.
This population does have significant health problems, and many of these
problems are nutrition-related and can be lessened by optimal food and
nutrient intakes and other nutrition-related services.

For congregate participants, the ENP provides nutritious meals and
opportunities for socialization that can help them stay active in their
communities. The evaluation shows that the ENP is very successful in
providing meals that meet current recommendations for intakes of
essential nutrients, but somewhat less successful in meeting the Dietary
Guidelines recommendations (such as providing diets with less total fat
and saturated fat) for preventing nutrition-related chronic diseases and
their complications. The evaluation also shows that the ENP provides
nutrition and supportive services in ways that participants perceive as
meeting their needs. The available scientific evidence suggests that
maintaining nutritional well-being in older people helps them mitigate
existing health problems, manage chronic conditions, prevent
complications associated with acute and chronic disease, and extend the
period of healthy living. In addition, the congregate component of the
ENP often provides related services, such as nutrition education and
counseling, to create healthier nutrition patterns for this group.

The recipients of home-delivered meals have greater needs for long-term
care services, and these needs are at least partially met by the ENP.
With an average age of 78, many home-delivered participants have
substantial numbers of chronic health conditions and functional
difficulties. Fewer than half get out of their homes as often as once a
week, and 77 percent are unable to do at least one everyday task without
assistance or can only do it with much difficulty. Furthermore,
substantial numbers of home-delivered participants\--about 15 to 20
percent\--rely on other types of long-term care services, such as
homemaker or personal care services, in addition to the meal program.
For many, the availability of a home-delivered meal is probably crucial
to their ability to function largely on their own. Additional evidence
of links to the long-term care system is provided by the substantial
number of home-delivered participants\--more than 40 percent\--who were
referred to the ENP by a community-based agency or organization.

Overall, both components of the ENP function within the continuum of
long-term care services. All levels of the ENP, from the SUA to the
projects, but particularly the AAAs and ITOs, are involved in the
management and delivery of long-term home- and community-based services.

AVERAGE MEAL COSTS The average total cost of a Title III congregate meal
is \$5.17. This includes \$4.46 in direct monetary costs and another
\$.71 in the value of volunteer labor and donated goods (Figure 7). The
overall cost for a home-delivered meal is slightly higher, at \$5.31
(\$4.57 in direct monetary costs and \$.74 in the value of volunteer
labor and goods). The costs of producing ENP meals appear reasonable in
light of information supplied by the National Restaurant Association. It
reports that, for the 12-month period ending November 1995, the national
average per-person cost for eating lunch was \$4.86 at cafeterias and
\$5.29 at \"family-style\" restaurants.10

![](media/image6.png){width="6.25in" height="4.729166666666667in"}

Costs for large projects (those serving at least 1,000 meals per week)
are lower than the average by \$.38 for congregate meals and \$.81 for
home-delivered meals. This pattern suggests that large projects may
achieve significant economies of scale in operating the ENP program.
Costs also tend to be lower for:

-   Rural projects

-   Projects using central kitchen production methods

-   Projects in the South and Midwest

The average costs for Title VI meals are \$1.00 to \$2.00 higher than
those for Title III. Total costs per Title VI meal, including donations,
are \$6.19 and \$7.18 for congregate and home-delivered meals,
respectively. Some of the higher costs may be due to the small scale on
which most Title VI sites operate, making it difficult for them to
achieve economies of scale. The magnitude of apparent economies of scale
(as estimated earlier with the Title III data), however, is not large
enough to explain the observed differences fully. The relative
importance of donated time and materials is substantially less for Title
VI than for Title III, however, with Title VI monetary costs at \$5.78
and \$6.78.

The bulk of ENP meal costs are either for labor or food. Together, these
categories make up 75 to 80 percent of Title III and Title VI meal
costs.

SOURCES OF FUNDING\
Federal and Other Contributions Federal Title III expenditures are
highly leveraged with money from other sources (Figure 8). Title III
funding accounts for approximately 37 percent of congregate costs and 23
percent of home-delivered costs. Despite participants\' low income
levels, their contributions account for 20 percent of both congregate
and home-delivered meal costs. Other major resources for the program
include the USDA cash in lieu of commodities program and state, local,
and private funds. In part, the high leveraging rates reflect the fact
that, by law, states are required to supply resources to match the
federal contribution.\
![](media/image7.png){width="6.25in" height="4.729166666666667in"}

For every \$1.00 in Title III funds for congregate meals, \$2.70 in
total resources is devoted to the program. A dollar of Title III funding
is thus supplemented with \$1.70 from other sources. The leveraging rate
for home-delivered meals is higher: a dollar of Title III funding is
supplemented with \$3.35 from other sources.

Most projects suggest contribution amounts for participants. These
amounts vary substantially, ranging from \$.50 or less per meal to more
than \$2.00. The majority of the suggested contributions are in the\]
range of \$1.00 to \$1.50. In the survey, 85 percent of respondents
indicated that they felt that their project\'s suggested contribution
was \"about right.\"

The value of volunteer labor accounts for about nine percent of Title
III meal costs. Thirty-five percent of Title III congregate participants
volunteer their time to perform program tasks, such as setting up meal
sites, collecting contributions, or delivering meals.

One interesting aspect of Figure 8 is that the average federal
contribution to a Title III congregate meal is considerably higher than
the average contribution to a home-delivered one. There appear to be two
related reasons for this pattern. First, many projects report that it is
easier to raise external funds for home-delivered meals because the need
for them is often more apparent to potential donors. Second, nutrition
projects may be trying to increase the number of home-delivered meals
they can supply by paying a higher percentage of the cost of these meals
out of resources from fundraising, compared with congregate meals, on
average. However, state and local contributions for both kinds of meals
are considerable.

In contrast, the leveraging rate for Title VI is considerably lower than
that for Title III. Unlike Title III, the Title VI program does not
require state or local matching of federal funding. Title VI grants are
the primary source of funding for the ENP: 61 percent of the resources
used to provide congregate meals and 73 percent of the resources used to
provide home-delivered meals come from Title VI grants (Figure 9 on the
next page). Title VI also draws revenue from other sources, including
tribal funds, USDA cash in lieu of commodities, and participant
contributions, but these sources generally contribute smaller
proportions of overall funding.

Flexibility in Fund Transfers Current law allows states to transfer part
of their Title III funding to different subcomponents of the program.
Policymakers are interested in whether states currently have enough
flexibility to respond to their individual needs. To examine this issue,
Mathematica analyzed state-by-state data on funding transfers. The
regulatory limits on transfers do not appear to restrict states from
shifting resources to components that need more funding. The key
findings include:

-   No state exceeded the limits on transfers between Title III-B
    supportive services and Title III-C nutrition services in the 10
    years examined.

-   There are more transfers between components of Title III-C than
    between Title III-C and Title III-B. Furthermore, the percentages
    transferred from Title III-C (congregate) to Title III-C2
    (home-delivered) have grown over time. However, most states do not
    seem constrained by the 30 percent limit on funding transfers
    between congregate and home-delivered meals.

-   States transferred about 17 percent of the funds initially allocated
    for the Title III congregate program to other uses in the 10 years
    examined. About two-thirds of the transferred funds went toward
    home-delivered meals; one-third went toward supportive services.

-   The New England and West Coast states transferred the highest
    percentages of funds into home-delivered meals.

![](media/image8.png){width="6.248611111111111in"
height="4.727777777777778in"}

CONCLUSIONS\
Accomplishments The results of the evaluation show that the ENP has
succeeded in accomplishing its mission of improving the nutritional
intakes of elderly people, as well as in decreasing their social
isolation. The evaluation also shows that the program is evolving to
meet the changing needs of older people brought on by shifting
demographics and changes in the health care system and public policy
environment. There are indications of unmet needs for the program\'s
services, as well as signs that there may be new roles for the program
in the future.

The ENP provides an average of nearly 1 million meals per day to older
Americans. These meals are targeted toward highly vulnerable elderly
populations, including the very old, people living alone, people below
or near the poverty line, minority populations, and individuals with
significant health conditions or physical or mental impairments. On
average, the meals provided easily meet the RDA requirements set forth
in the OAA, and they significantly increase the dietary intakes of ENP
participants.

The ENP also reduces the social isolation of older Americans in both the
congregate and home-delivered programs. Although the accomplishment of
this goal is more obvious in the congregate program, participants\'
contacts with meal deliverers and links with other services in the
home-delivered program also reduce the isolation of homebound elderly
people.

Agencies at the various administrative levels of the program\--SUAs,
AAAs, ITOs, and nutrition projects\--have forged close links with other
parts of America\'s emerging home- and community-based long-term care
system. Federal dollars spent on the ENP are highly leveraged and
supplemented with the financial resources of state, tribal, and local
private and public sources. Despite participants\' low income levels,
their contributions account for 20 percent of both congregate and
home-delivered meal costs. Local donations and volunteer time, often
from program participants, account for 14 percent of costs.

Future Challenges By most measures, the ENP is a highly successful
program that has a positive influence on an overwhelming majority of its
participants. Yet many challenges on the horizon could shape the future
of the program.

The changing demographics of the U.S. population suggest different and
increasing needs for program services, particularly in the area of
home-delivered meals. The evaluation indicates that the pool of persons
needing home-delivered meals and other nutrition services is not limited
to those who have \"aged in place\" within the congregate meal program.
In fact, the majority of participants in the home-delivered program have
never received congregate meals. Rather, future needs for home-delivered
nutrition services will be driven in part by the increase in the number
of elderly people, especially the \"oldest old\"\--those 85 years and
older\--who are expected to double in number by the year 2030. This
population is most vulnerable to disabling conditions that hinder their
ability to live independently in the community.

Changes in participant characteristics will influence program
operations, including the need to provide a continuum of nutrition
services and to tailor meals and services to better meet the specialized
nutritional needs of both congregate and home-delivered participants.

The changing health care system will also affect the operation of the
ENP. As hospitals and nursing homes discharge elderly people more
quickly into the community, community service agencies will be expected
to provide some services that may have previously been delivered in
health care facilities. As a result, the ENP will be called on to
provide services to a growing number of frailer, sicker, and more
functionally impaired older persons than in the past.

Changes in the public policy environment, such as efforts to reduce the
size of the federal deficit and the devolution of decision making to the
states, also have potential to shape the ENP in the future. In many
ways, the ENP already reflects a number of these shifts, with its
emphasis on state and local planning, its extensive reliance on local
decision making, and its use of volunteer contributions and local
donations. Nonetheless, the ENP will be challenged to meet increasing
demands at a time of decreasing federal funding.

There are other indications of the challenges that lie ahead. The
evaluation found that 41 percent of Title III home-delivered programs
and 9 percent of congregate programs have waiting lists for meals, and
22 percent of Title III nutrition projects have waiting lists for other
nutrition and supportive services. It is likely that these figures
underestimate the number of nutrition projects that must limit their
services, because some projects probably do not maintain waiting lists.
Furthermore, 64 percent of congregate and 88 percent of home-delivered
participants remain at high or moderate nutritional risk, as assessed by
factors used in the Nutritional Screening Initiative. This significant
risk is borne out by nutritional risk factors: two-thirds of
participants have weights outside the healthy range, one- to
three-fourths have functional impairments, between 10 and 17 percent
reported recent instances of food insecurity, and most participants have
two or more nutrition-related chronic health conditions.

Another challenge for the ENP is to reduce the total and saturated fat
content of program meals to meet the Dietary Guidelines, without
compromising the program\'s ability to provide participants with much
needed calories and essential nutrients. The ENP will also be challenged
to find better ways of producing meals as cost-effectively as possible
and maintaining or improving food safety and sanitation practices.

To remain successful, the ENP must continue to adapt to changes in
demographics, the health care system, and the public policy environment.
The program will be called on to meet the need for more meals and other
nutrition services, to target services to the most nutritionally needy,
to become more efficient and effective, and to leverage additional funds
in an environment of shrinking federal resources. The ENP must confront
these and other challenges in the future in order to enhance the health,
functioning, and quality of life of older people while helping them
avoid unnecessary and costly institutionalization, all in order to
continue its mission of ensuring adequate nutrition for older Americans.

#### NOTES

1\. Nutrition-related and supportive services, such as transportation to
and from meal sites, shopping assistance, information and referral, case
management, homemaker and home health aide services, outreach, and
nutrition counseling and education, are also provided under Title III-B.
Funding for these services was \$307 million in FY 1994, but not all are
nutrition-related.

2\. In FY 1994, USDA provided approximately \$150 million in such
assistance.

3\. Details of the data collection methodologies are presented in the
full report.

4\. These comparisons are made with the overall elderly population in
the United States rather than with the comparison group, because the
comparison group was selected to be similar to the participant group, in
order to maximize the precision of the impact analysis.

5\. In certain cases, the OAA allows services to Title III participants
under age 60. For example, spouses of participants age 60 or older may
be under age 60. Also included are disabled persons under age 60 who
live in housing facilities that serve congregate meals, as well as
disabled persons who reside at home with, and accompany, elderly
participants age 60 or older to an ENP site. For similar reasons, Title
VI participants may be younger than the minimum age established by the
ITO.

6\. The results reported here are based on weighting the sample to make
it representative of persons served by the program on a typical day and
thus reflect the population receiving the bulk of program resources. As
discussed in the full report, when the data are weighted to reflect the
overall population of participants who ever attend the program\--thus
equally weighting infrequent and frequent participants\--the estimated
percentages of minorities go down somewhat but still remain higher than
their proportions in the overall population.

7\. The OAA requires projects to serve meals at least five days per
week. Programs in rural areas, if approved by the SUA, may serve meals
fewer than five days per week, if serving five is not feasible.

8\. The OAA requires all Title III projects to offer nutrition
education. It is not clear whether the ones that report not doing so are
out of step with the law or misunderstood the relevant questions on the
survey.

9\. For example, it has been estimated that the number of cases of human
salmonellosis reported to the Centers for Disease Control each year
represent from one percent to five percent of the actual yearly
incidence of this infection in the United States (Richard B. Chalker and
Martin J. Blaser, \"A Review of Human Salmonellosis: Magnitude of
Salmonella Infection in the United States,\" vol. 10, no. 1,
January-February, pp. 111-124, 1988). If we apply this rate of
underreporting to the approximately 200 participants that AAAs reported
as getting sick from program meals in the past three years, then between
4,000 and 20,000 participants probably actually became sick from the
meals. In other words, no more than one percent of ENP participants
contacted food-borne illness from program meals.

10\. Source is personal communication with Susan Mills, Research
Division, National Restaurant Association, Washington, DC, May 1996.